Effective Patient Communication During End-of-Life Discussions

In 2005, Steve Jobs was diagnosed with cancer. Later that year, the typically stoic Jobs demonstrated uncharacteristic vulnerability during a commencement address at Stanford University. In front of thousands of people, Jobs proclaimed, "No one wants to die. Even people who want to go to heaven don't want to die to get there. And yet death is the destination we all share."

In that moment, Jobs affirmed the obvious: Death is both scary and inevitable. As a clinician, patient communication during end-of-life discussions can be the most challenging and emotionally taxing aspect of health care. Fortunately, there are proven methods for how to communicate with your patients effectively and compassionately during these situations to help them feel more comfortable with their choices.

Good Communication Practices

A recent systematic review published in the Journal of Pain and Symptom Management revealed the most important actions for effective end-of-life patient communication:

• Prognosis: Patients and caregivers typically prefer a complete prognosis that's offered simultaneously with the diagnosis.
• Tailor information: Information should be customized to both the caregiver and patient. Everybody's needs are different and often vary throughout the course of an illness. As the illness progresses, caregivers typically prefer far more information than the patient does.
• Provide sufficient information: Patients and caregivers generally want to have complete information regarding the diagnosis and prognosis, as well as any other information that guides clinical decision-making. Proper understanding can be ensured through a series of questions and answers.
• Communication. Both patients and caregivers usually prefer information that is simple, direct, and delivered with empathy, compassion, sensitivity, and hope.

Motivational Interviewing

Consider using motivational interviewing to help with patient communication. Motivational interviewing is a proven patient communication tactic for improving adherence, understanding, and outcomes. As adapted from a 2008 article published in The British Journal of General Practice, here are five techniques (including examples) that teach how to apply motivational interviewing techniques during end-of-life situations:

• Get the patient involved in the process: Help the patient or caregiver understand the diagnosis and prognosis in a systematic manner, and have them assist in developing the care plan. Example: "So now that you are fully aware of this illness, let's work together to decide where to go from here."
• Express empathy: Show sensitivity by expressing your understanding of the situation. This will help develop a trusting relationship with the patient. Example: "Cancer is a physically and emotionally challenging disease, but from the little time I've known you, it's clear that you are a strong person with an amazing support system. Please know that I'll be here for you every step of the way."
• Roll with resistance: As the provider, attempt to practice patience so that you don't make resistance worse. You can then subtly suggest certain things to get the patient thinking. Example: "You're right, you may no longer need therapy. I'm really proud of you — look how far you've come. If we stop now, though, how do you think you'll be in a month or two?"
• Elicit, provide, elicit: In order to determine the patient's current level of understanding (and fill in any gaps of misunderstanding), create a dialogue in which you and the patient are both explaining and confirming treatment. This ensures that everybody has a clear understanding of the diagnosis, prognosis, and symptom management. Example: "Mr. Smith, can you tell me how you're supposed to take your medication?" ... "That's exactly right. Remember also only to take it at night. Is there anything that may prevent you from taking your medication regularly?"
• Provoke change talk: Instill hope by evoking the patient's reasons or desires for continuing to live. Ask about loved ones and passions. Once they hear it from themselves, they are more likely to follow their care instructions. Example: "Why do you want to continue on dialysis? Are you excited about your granddaughter's recital?"

As a doctor, you may see patients die in any given year, but remember that you entered health care to help. Whether it be hands-on medical care or purely emotional support, your patients need you the most when they are nearing death. As Jobs noted, "Almost everything — all external expectations, all pride, all fear of embarrassment or failure — these things just fall away in the face of death, leaving only what is truly important." As the doctor, you play arguably the most important role in your patient's life as they near death. The method of communication can be the difference between an end-of-life experience that is filled with the typical rigors and stress of life or one that is spent celebrating a life well-lived.