How Should I Talk to Terminally Ill Patients?

Alexander J. Millman, MD

Disclosures

April 03, 2013

Question

I find it uncomfortable when terminally ill patients ask questions about their prognosis. How should I approach the topic?

Response from Alexander J. Millman, MD
Resident Physician, Internal Medicine, University of California-San Francisco

The oncologist told me that there were no treatments left for this patient with metastatic cancer: no chemotherapy, radiation therapy, or surgery. Further treatment would not alter the patient's prognosis. I took a moment to collect my thoughts before going into the room to meet the patient for the first time.

"So, Doc, what are we going to do?"

Physicians discuss medical conditions with their patients countless times a day, and although experience helps us become more comfortable addressing many topics, talking to terminally ill patients about their conditions can leave even the most experienced physicians searching for the best ways to broach these sensitive issues. These discussions require delicate skill and an emphasis on patient-centered communication. It is important to keep an open mind and to remember that the patient may be uncomfortable too.

There is no one-size-fits-all dialogue to use, but here are some principles and strategies that I have found helpful in approaching terminally ill patients.

Prior to meeting the patient, I try to learn as much as I can about the patient's diagnosis and prognosis by reviewing the medical record and, when possible, addressing any questions with consultants. In fact, communicating with a specialist who has cared for the patient in the past can be especially helpful. Many patients with terminal conditions already have established relationships with other physicians. Getting input from those providers can be invaluable for framing the conversation with the patient.

When you meet the patient for the first time, try to maintain a nonjudgmental manner by asking open-ended questions. You want to elicit patients' thoughts about their disease and allow them to express any concerns they may have. Some patients will have incredibly well-informed and nuanced understandings of their condition and prognosis, while others may not have discussed their illness before. Simply asking, "What do you understand about your disease?" can provide a foundation for future conversations while enabling the patient to express any concerns or anxieties from the start.

For example, if the patient states that his biggest concern is the dry mouth caused by treatment, then failing to address that issue (even if it means saying that there are no available treatment strategies) sets up an immediate barrier to forming an effective doctor-patient relationship.

Discussing the patient's prognosis can be the most challenging task because, despite all our advances, accurate predictions remain elusive. Available data generally are based on population studies and do not necessarily correlate with an individual patient experience. In addition, patients approach death with different preconceived ideas, with some vowing to "beat the odds." Therefore, although we want to answer patients' questions, we need to be honest about what we know and what we don't know. Admitting that we don't have all of the answers can humanize the interaction by reducing the appearance of professional arrogance and aloofness.

Although seemingly complex, discussions with patients who are terminally ill should follow principles that are similar to all physician-patient interactions. Asking nonjudgmental questions, eliciting patient concerns, and explaining the medical knowledge or its limits can make these patient interactions highly informative and rewarding. Creating a trusting relationship from the beginning enables subsequent interactions to flourish even in the most challenging circumstances.

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