Physicians are also squeamish about Advance Care Planning discussions!

The Vancouver Sun featured an article, "Refusal to face reality of death leads to increased use of aggressive, futile health-care efforts: Doctor calls on Canadians to 'normalize conversations' about end-of-life care"

It's great to see this kind of story popping up across the news. The more we talk about it, the less scary it is to discuss; the end result is that we'll provide less futile care and offer better palliation, sooner, meaning that patients can have the best possible quality of life until the end.

The title of the video basically says it all; cardiologist Dr Heather Ross talks about the challenges that physicians face when they need to talk with patients about end of life care. It's interesting that she should remark on her discomfort with these kinds of discussions, as that was not something that came up in the study that prompted this Sun feature. 

The study in JAMA Internal Medicine is Barriers to Goals of Care Discussions With Seriously Ill Hospitalized Patients and Their Families: A Multicenter Survey of Clinicians. You at al. surveyed 1256 Canadian health care providers to identify some of the major challenges with discussing end of life situations and they identified the following:

  • family members' or patients' difficulty accepting a poor prognosis

  • family members' or patients' difficulty understanding the limitations and complications of life-sustaining treatments

  • disagreement among family members about goals of care

  • patients' incapacity to make goals of care decisions

Clinicians did not view system factors as significant barriers to these discussions, which I find surprising since we usually talk about underfunding, overcrowding, paperwork, communication errors, and bureaucracy whenever we have a tough problem to solve.

Interestingly, health care providers did not feel that their own skills presented major barriers to having care planning discussions. Well! I find that hard to believe. Clinician factors probably contribute greatly and we seem to have a blind spot for our own weaknesses!  

Fortunately Dr You acknowledges this:

“Overall, the sense from the clinicians is that patients and families tend to get in the way” of making concrete decisions about a patient’s care plans, You said. “This is what they perceive,” You said. 
“But I think it reflects that if patients and families are having a difficult time, then one of the solutions clearly has to be that physicians need to be skilled communicators — they need to know how to navigate these sometimes emotional or difficult discussions and be sensitive,” he said

A clinician's personal discomfort, uncertainty about prognosis, fear of not being liked, and other individual factors are definitely contributors to the difficulty of talking about dying with patients. A lot of the things that make it hard for doctors and nurses to talk with patients about planning for death and dying also contribute to the more general problem of inappropriateness in health care. 

So what can we do? Start here: It's Time to Talk: Advance Care Planning in BC. 

I'm proud to be a part of the Doctors of BC Council for Health Economics and Policy (CHEP), which is where Dr. David Attwell  spearheaded the creation of this policy paper.

Take a look. It's never too late to start talking about it!

Choosing Wisely: Five Things Nurses and Patients Should Question

Nurses are on the frontline of medicine. They know their patients well, support them through every moment of their stay in hospital, and are responsible for a lot of decisions that can help (or harm) patients. 

Since providing high-value and safe care is not just about decisions in the patient-physician encounter, the Choosing Wisely initiative have partnered with The American Academy of Nursing to create a list of 5 things Nurses and Patients should question: 

  1. Don’t automatically initiate continuous electronic fetal heart rate (FHR) monitoring during labor for women without risk factors; consider intermittent auscultation (IA) first.
  2. Don’t let older adults lay in bed or only get up to a chair during their hospital stay.
  3. Don’t use physical restraints with an older hospitalized patients
  4. Don’t wake the patient for routine care unless the patient’s condition or care specifically requires it.
  5. Don’t place or maintain a urinary catheter in a patient unless there is a specific indication to do so.

Read in more detail at Choosing Wisely or see the PDF.

The American Academy of Nursing is not the only non-physician group to have their own list; the American Physical Therapy Association (APTA)  also has a list. In addition, there has been broad collaboration with representatives of the other professional roles in the health care team during the development of The Choosing Wisely campaign.

Many of the society lists were created with the involvement of multidisciplinary teams and patient groups, recognizing the fact that it's going to take engagement at all levels to make a meaningful change that is good for patients and good for our healthcare system.