Dr. Janet Abrahm was in a hospital cafeteria when she heard the oncologist and his patient nearby.
“Your husband isn’t here?” he said. “OK, well, let me tell you anyway. Your leukemia has returned.”
Doctors generally overestimate their own communication skills, research shows. But when it comes to breaking bad news, even seasoned doctors often fail to handle such situations as well as they may hope.
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Abrahm, a Harvard Medical School professor who also trains midcareer physicians at Dana-Farber Cancer Institute, is one of a growing legion of palliative specialists who are hoping to change that at a pivotal time for the medical industry. Starting this month, Medicare began reimbursing doctors for end-of-life conversations with patients, in which doctors gauge the patients’ preferences for aggressive life-saving treatments and palliative care.
Some researchers are exploring the optimal timing for such conversations — whether, for instance, it’s possible to identify patients who’ve begun their final decline.
And there’s ongoing debate about which doctor should be the one to break the news — be it a primary care physician, specialist, or emergency room doctor — or, indeed, whether it’s best left to family members to discuss around the kitchen table.
The question of how to engage in such a discussion takes on deeper urgency when someone has a terminal illness.
Abrahm, in her training, espouses an approach that’s tailored to doctors, of course, but that would also serve family members who might wish to broach the subject with loved ones.
“This is a conversation that takes an awareness of the good it’ll provide to the patient and the family, and an understanding that it not only doesn’t take hope away, but it enhances hope and purpose for the things that really need to get done,” she said.
Palliative specialists generally break the conversation into a series of steps.
The first step, many said, is simply asking the patient their understanding of their health status, because they often know intuitively what is happening with their bodies. And while some patients wish to have their prognosis aired openly, others might not want to know.
If they want to know, and the news is bad, Abrahm said it helps to have a spouse, or a close friend, or relative there for support.
When it comes time to deliver the prognosis, she said, “Tell her some information and check to see how much information they want.”
Avoid phrases like “nothing more can be done,” she and others said, because even when giving a terminal diagnosis, much can be done. Goals shift. Patients and families often seek to optimize their remaining time together, and treatments can be modified to help families meet those goals.
So when delivering the worst news, palliative specialists say it’s better to, instead, convey the message that there are no more options for cures.
“And then you have to shut up,” Abrahm said.
Abrahm added that she coaches people to count to 20 before speaking again. It is an eternity for many people. “They’re so uncomfortable with silence.”
“Then it’s, ‘How are you doing?’ And, ‘What can I do for you?’”
“If they have good time left, they can make some choices,” she said. “‘We have work to do,’ we’ll often say.”
More medical schools are training students on all aspects of palliative care, including end-of-life conversations, but older doctors present challenges.
“Teaching midcareer physicians is a tough piece to get at,” said Dr. Kate M. Lally, director of palliative care at Care New England Health System, in Providence, R.I. “We learn best by working with specialists, by watching and listening.”
But few programs are set up to teach midcareer physicians, Lally and others said, and many doctors lack the time for training sessions that involve simulations, feedback, and coaching. And even those with the time may lack the desire to embrace end-of-life conversations.
“I had an interaction recently with an oncologist about a patient,” Lally said. “We were a little at odds. She said, ‘Kate, we both went into medicine to save lives,’ which startled me.
“Most of us treat chronic conditions, but the ‘save lives’ thing isn’t the bulk of what we do in medicine.”
Yet the idea that medicine is entirely about saving lives, Lally said, leaves no room for acknowledging death, and helping patients manage their final months.
One solution is for doctors to engage each other in end-of-life conversations, as they do in training programs offered through the Institute for Healthcare Improvement and the Conversation Project.
“Having a conversation and going through it from the patient’s side, I think, does change their outlook,” Lally said. “But I don’t think it’s having or not having the conversation. I think it’s bigger factors: the culture, how we’re trained, and being on the patient side.”