Summer 2017

Discussing End-of-Life Care

Harris BermanAs medical professionals, most of us have experienced some variation on the following scene: An elderly patient is in a coma, her hospital bed surrounded by family members. Her long-lost son feels guilty because he hasn’t visited his aging mother in five years and now wants everything that can possibly be done to keep her alive—he may not be thinking about what’s best for Mom, per se. His three sisters are more realistic about the prognosis. Yet because the patient has no designated health proxy, you don’t know whom to listen to or who’s in charge.

Such a difficult situation can be avoided with honest (and early) discussions about end-of-life plans. That’s where the newly formed Massachusetts Coalition for Serious Illness Care comes in. Health professionals from across the Bay State are working together to further the coalition’s mission: “To ensure that health care for everyone in Massachusetts is in accordance with their goals, values and preferences at all stages of life and in all steps of their care.”

In 2016, the coalition conducted a survey and found while 85 percent of Massachusetts residents believe physicians and their patients should talk about end-of-life care, only 15 percent have had such conversations. Plus, one-third of those polled who had a loved one die in the past year said patient preferences were not fully followed—and one-fifth described the end-of-life care they witnessed as only fair or poor. (Read the report at maseriouscare.org.)

One of the group’s core priorities is to make sure clinicians are adequately prepared to communicate with patients about end-of-life expectations, which is why coalition co-chair Dr. Atul Gawande approached me last year about collaborating on curriculum changes around these issues. I have great admiration for Dr. Gawande—he’s a surgeon, writer and researcher who I think has done more for public health in the world than anyone else I know—and have since met with the academic deans from Massachusetts’ four medical schools to kick off the conversation about how best to train our students to give them the tools they need to do this important work.

I think language is one of the keys in helping students feel comfortable broaching the subject. Talking about death can be tricky—so it’s easy to avoid! But if you talk about end-of-life goals, it seems less ominous. Taking the medical history of a new patient is a good place to start. If you find that a patient’s parents are deceased, you can use that as an entrée. Does she want to be treated the way her parents were in their final days? Has she nominated a proxy should she become incapacitated? Once you bring it up, patients are often happy, even relieved, to chat about it.

Students should also be aware that it’s an ongoing discussion. They need to periodically check in with a patient about his wishes, just as a patient needs to share these evolving wishes with his proxy and family. Take my own situation: I had a heart attack at age 48. An episode like that makes you very aware of your mortality and so my wife and I talk through our end-of-life plans over and over with our kids; they sometimes think we’re a bit morbid!

Although students already learn about end-of-life care at Tufts—and at the state’s other medical schools—we intend to share best practices and standardize the training. It can’t be achieved with one lecture. Like ethics, end-of-life planning is an issue that comes up all the time; it needs to be a continual lesson during the clinical years.

The next step is to get input from faculty and staff before curriculum changes are adopted. In the meantime, there are two upcoming events at Tufts focused on these issues. The keynote speaker for the Class of 2021’s White Coat Ceremony on September 9 is alum Dawn Gross, M.D., Ph.D., a writer and educator who hosts the “Dying to Talk” radio program.  And all incoming medical students are reading Dr. Gawande’s 2014 best seller Being Mortal—the Common Book for fall—in advance of his on-campus Dr. Maurice Segal Lecture on September 15. These talks should help introduce the topic.

Harris A. Berman, M.D., Dean, Tufts University School of Medicine

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