Breaking News
September 24, 2018 - Second HPV-Related Primary Cancers Common in Survivors
September 24, 2018 - How a virus destabilizes the genome
September 23, 2018 - Smart textile-based soft robotic exosuit helps wearers save energy and traverse difficult terrain
September 23, 2018 - New research hub to drive radical change in development and manufacturing of vaccines
September 23, 2018 - AHA: For Hispanics, Neighborhood May Be Key Factor in Heart Disease Risk
September 23, 2018 - Excessive airway nerves tied to more severe asthma symptoms, study finds
September 23, 2018 - Study highlights need to remain vigilant in maintaining key infection control processes
September 23, 2018 - Novel therapeutic strategy for blood vessel related disorders, such as cancer and retinopathy
September 23, 2018 - New naturally occurring antibiotic found effective against Mycobacterium tuberculosis
September 23, 2018 - First-in-human phase 0 study shows clinically-relevant activity of new drug in glioblastoma
September 23, 2018 - Removing tobacco product display from shops reduced number of children buying cigarettes
September 23, 2018 - Random fraction of specialized immune cells leads the charge in battling invaders
September 23, 2018 - Few minutes of sprinting exercise may be as effective as longer exercise sessions
September 23, 2018 - Researchers use neutrons to make first direct observations of water in lipid bilayers
September 23, 2018 - Researchers demonstrate pre-clinical success for universal flu vaccine in new paper
September 23, 2018 - Study reveals surprising gaps in some HIV medical providers’ knowledge of ACA
September 23, 2018 - Oxehealth secures European medical device accreditation for vital signs measurement software
September 23, 2018 - HTN Tx Intensification Common Upon Discharge in U.S. Vets
September 23, 2018 - Fibre can strengthen the intestinal barrier
September 23, 2018 - New platform examines infectious pathogens that may spread from animals to humans
September 23, 2018 - Demographers create detailed color map of population aging in Europe
September 23, 2018 - New type of fatty acid can slow down overreactive immune system
September 23, 2018 - Innovative procedure could provide breakthrough in treating early-stage lung cancer
September 23, 2018 - Research finds drop in number of measles cases in the EU/EEA since March 2018
September 23, 2018 - Researchers acquire new insights into DNA polymerases
September 23, 2018 - Alzheimer’s diagnosis might become simpler with new brain imaging method
September 23, 2018 - Reports Warn of Growing Opioid Crisis Among Seniors
September 23, 2018 - Researchers unravel why people with HIV suffer from more neurologic diseases
September 23, 2018 - Human brain structured to make best possible decision with limited resources
September 23, 2018 - KHN’s ‘What the Health?’ Health on the hill
September 23, 2018 - Bad air and inadequate data prove an unhealthy mix
September 23, 2018 - Regular bedtime and wake time important for heart, metabolic health even among adults
September 23, 2018 - HIV and a tale of a few cities
September 23, 2018 - NIH launches clinical trial to test infusions of combination antibodies in people with HIV
September 23, 2018 - Researchers develop new system to detect consumption of synthetic cannabinoids
September 23, 2018 - Vax-Hub to influenze radical change in development and manufacturing of vaccines
September 23, 2018 - People who have slept lesser than seven hours have higher risks of car crashes
September 23, 2018 - an ancient art may work best to prevent falls in old age
September 23, 2018 - Consumption of foods with lower nutritional quality related to increased cancer risk
September 23, 2018 - Patient Health Information Often Shared Electronically
September 23, 2018 - Can machine learning bring more humanity to health care?
September 23, 2018 - Body organs undergo structural changes in response to diet
September 23, 2018 - Genetic polymorphisms linked with muscle injury and stiffness
September 23, 2018 - As states try to rein in drug spending, feds slap down one bold Medicaid move
September 22, 2018 - Why Eczema Is Tougher to Treat for Black Patients
September 22, 2018 - Team reveals that human genome could contain up to 20 percent fewer genes
September 22, 2018 - USC research uncovers previously unknown genetic risk factor for Alzheimer’s disease
September 22, 2018 - Novel method achieves accurate and precise temperature estimation in fat-containing tissues
September 22, 2018 - BSI accredits Oxehealth’s vital signs measurement software as Class IIa medical device
September 22, 2018 - Evolution of psychiatric disorders and human personality traits
September 22, 2018 - Obesity in early puberty doubles asthma risk for boy’s future offspring
September 22, 2018 - World’s most advanced real-time patient monitoring platform receives key US patent
September 22, 2018 - Study explores connection between sexuality and cognitive status in older adults
September 22, 2018 - LSTM partners with TB Alliance to develop novel TB drug regimens
September 22, 2018 - Annual wellness visits improve delivery of preventive services in elderly population
September 22, 2018 - CHMP provides positive opinion to Cabometyx for previously-treated patients with hepatocellular carcinoma
September 22, 2018 - Hispanic communities with high proportions of Hispanics face more cardiovascular-related death
September 22, 2018 - Vici syndrome – Genetics Home Reference
September 22, 2018 - Single-dose drug can shorten flu symptoms by about a day, studies suggest
September 22, 2018 - AMSBIO launches circulating tumor DNA Reference Standards
September 22, 2018 - Sandalwood mimicking odorant could stimulate hair growth in humans
September 22, 2018 - Overlooked immune cells could play a key role in cancer immunotherapy, claims new study
September 22, 2018 - Study reveals prevalence of diagnosed type 1 and type 2 diabetes among American adults
September 22, 2018 - Researchers develop fast detection strategy to know type of virus acquired by patients
September 22, 2018 - Global Prevalence of Insufficient Activity 27.5 Percent
September 22, 2018 - Strategies to protect bone health in hematologic stem cell transplant recipients
September 22, 2018 - Brigham Genomic Medicine program unravels 30 medical mysteries
September 22, 2018 - New system harnesses power of bubbles to destroy dangerous biofilms
September 22, 2018 - Inflammation plays crucial role in preventing heart attacks and strokes, study reveals
September 22, 2018 - Calorie dense, nutrient deficient meals common across the world
September 22, 2018 - Researchers develop technology to study behavior of implants without animal testing
September 22, 2018 - First gut bacteria in newborns may have lasting effect on ability to ward off chronic diseases
September 22, 2018 - Detection of BFD virus in parrots in 8 new countries raises concerns for threatened species
September 22, 2018 - Insulin treatment shows great potential against chronic bowel inflammation
September 22, 2018 - ‘Liking Gap’ Might Stand in Way of New Friendships
September 22, 2018 - Simple factors that can avoid harmful side effects in type 2 diabetes
September 22, 2018 - ALSAM Foundation invests additional $2 million for drug discovery and development projects
September 22, 2018 - Study findings may advance discussion of how to effectively curb human-wildlife conflict
September 22, 2018 - Dopamine neurons may involve in conditions ranging from Parkinson’s disease to schizophrenia
September 22, 2018 - Protein C and Protein S Tests: MedlinePlus Lab Test Information
Doctors learn how to talk to patients about dying

Doctors learn how to talk to patients about dying

image_pdfDownload PDFimage_print

Lynn Black’s mother-in-law, who had lupus and lung cancer, was rushed into a hospital intensive care unit last summer with shortness of breath. As she lay in bed, intubated and unresponsive, a parade of doctors told the family “all good news.”

A cardiologist reported the patient’s heart was fine. An oncologist announced that the substance infiltrating her lungs was not cancer. An infectious-disease doctor assured the family, “We’ve got her on the right antibiotic.”

With each doctor’s report, Black recalled, most of her family “felt this tremendous sense of relief.”

But Black, a doctor herself, knew the physicians were avoiding the truth: “She’s 100 percent dying.”

“It became my role,” Black said, to tell her family the difficult news that her mother-in-law, who was in her mid-80s, was not going to make it out of the hospital alive. Indeed, she died there within about a week.

The experience highlights a common problem in medicine, Black said: Doctors can be so focused on trying to fix each ailment that “no one is addressing the big picture.”

Now Black, along with hundreds of clinicians at Massachusetts General Hospital in Boston, is getting trained to talk to seriously ill patients about their goals, values — and prognoses — while there’s time to spare.

The doctors are using a script based on the Serious Illness Conversation Guide, first created by Drs. Atul Gawande and Susan Block at Ariadne Labs. Since its inception in Boston in 2012, the guide has been used to train over 6,500 clinicians worldwide, said Dr. Rachelle Bernacki, associate director of the Serious Illness Care Program at Ariadne Labs.

At Mass General, Dr. Juliet Jacobsen, a palliative care physician, serves as medical director for the Continuum Project, a large-scale effort to quickly train clinicians to have these conversations, document them and share what they learn with one another. The project ramped up in January with the first session in a series that aims to reach 250 primary care providers at the hospital.

For patients with advanced cancer, end-of-life conversations with clinicians take place a median of 33 days before a patient’s death, research shows. When patients have end-stage diagnoses, fewer than a third of families recall having end-of-life conversations with physicians, another study found.

That’s despite evidence that patients have better quality of life, fewer hospitalizations, more and earlier hospice care and higher satisfaction when they talk to doctors or other clinicians about their values and goals, according to recent research.

At a recent training session, Jacobsen gave clinicians a laminated page with scripted language to help them along. When the participants role-played with professional actors, difficulties quickly emerged.

Dr. Thalia Krakower, a primary care physician, faced an emotional “patient” whose condition was on the decline.

“I can’t imagine it being any worse,” said the patient, hanging her head in tears.

“How long should we let them be silent and sad?” Krakower asked Jacobsen. “We always step in too soon.”

Physicians let patients speak an average 18 seconds before interrupting them, research has found. Jacobsen encouraged doctors to allow more silence, and to respond to patients’ emotions, not just to their words.

The scripted conversation is quite different from what doctors have been trained to do, Jacobsen acknowledged. It doesn’t aim to reach any decision, nor to fill out end-of-life paperwork.

“For the average doctor, this might feel like you’re not getting anything done,” she said. The goal is to step back from day-to-day problem-solving and talk about the patients’ understanding of their illness, their hopes and worries, and the trajectory of their disease.

In a pilot at Brigham and Women’s Hospital in Boston, Jacobsen noted, the conversations typically lasted 22 to 26 minutes.

At another moment during role-play, Jacobsen stepped in when a doctor skipped over the section in the script where she was supposed to share prognostic information.

The topic is avoided for many reasons, Jacobsen later said: Clinicians’ schedules are crammed. They may not want to scare families with a timeline that turns out to be wrong. And they may not know what language to use, especially when the disease trajectory is uncertain.

When a doctor’s message moves abruptly from “everything’s great” to “she’s dying,” Jacobsen said, patients and their families don’t have enough time to adjust to the bad news.

To address that problem, Jacobsen’s team suggests language that helps clinicians discuss a prognosis without asserting certainty: “I worry the decline we have seen is going to continue,” or, “I worry something serious may happen in the next few months.”

After the training, Jacobsen’s team plans to follow up with doctors to make sure they are having the conversations with patients, starting with those deemed likely to die within three years.

The guide is also being rolled out at Baylor Scott & White Health in Texas, Lowell General Hospital in Massachusetts, the University of Pennsylvania and hospitals in 34 foreign countries, Bernacki said.

And Ariadne Labs has teamed up with VitalTalk, a communications training company, and the Center to Advance Palliative Care to rapidly disseminate the Serious Illness Conversation Guide across the country. They aim to train 200 trainers by June 2019, Bernacki said. (This initiative and other activities at Ariadne Labs are funded by the Gordon and Betty Moore Foundation, which also supports some of KHN’s reporting.)

Right now, she said, whether patients have these discussions depends too much on geography. “Our goal,” she said, “is for every patient with serious illness to have a meaningful conversation about what they care about, in every place.”

KHN’s coverage of end-of-life and serious illness issues is supported in part by the Gordon and Betty Moore Foundation.


Kaiser Health NewsThis article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

Tagged with:

About author

Related Articles