End-of-Life Discussion Guide Aids Physician–Patient Planning

Laurie Barclay, MD

July 15, 2013

An end-of-life "conversation guide" published online July 15 in the Canadian Medical Association Journal provides recommendations to guide physicians through sensitive discussions with hospitalized patients and their family members.

"[A] stay in hospital presents an important opportunity for engaging in discussions about goals of care, because it signals a change in the trajectory of the patient's illness, giving increased relevance to these conversations, and because potential substitute decision-makers (e.g., the most involved family members) are often present," write John You, MD, from the Department of Medicine and the Department of Clinical Epidemiology and Biostatistics at McMaster University in Hamilton, Ontario, Canada, and colleagues from the Canadian Researchers at the End of Life Network (CARENET).

"By providing structured guidance, specific advice and practical tools, our aim is to increase clinicians' confidence in engaging in meaningful end-of-life communication with patients in hospital and their family members," they continue.

The impetus behind these guidelines includes the aging population and longer life expectancy for people with chronic illness, necessitating informed decision-making and compassionate discussions regarding end-of-life care. To address these issues, the authors reviewed relevant evidence from targeted searches of MEDLINE through July 2012.

The guidelines address critical issues underlying such decision-making, including identifying patients at high risk for imminent death, communicating prognosis, determining patient values as they affect the care plan, involving surrogate decision makers in care planning, and documenting a patient's wishes.

Although the guidelines primarily target hospital physicians, the authors acknowledge that primary care clinicians should play a key role in advance directives planning. They also recommend initiatives to increase public awareness outside hospitals about the importance of advance end-of-life care planning and the limitations of life-sustaining technologies.

"Clinicians should exercise judgment and flexibility in engaging patients and family members in these discussions, recognizing that determining goals of care is a process," the guidelines authors conclude. "For patients who have existing advance directives, this process may be straightforward; for others who may be less prepared, the discussion may best unfold in a phased approach, with initial introduction and probing of this issue early during the stay in hospital and more detailed follow up later on."

Specific Recommendations

  • To identify high-risk patients for whom end-of-life planning is needed, clinicians can use the "surprise" question ("Would I be surprised if this patient died in the next year?") or more detailed clinical criteria. These include age 55 years and older and 1 or more advanced chronic illnesses or age 80 years and older and hospital admission for an acute medical or surgical condition.

  • Clinicians should ask patients which family members they would like to have participate in goals-of-care discussions and should include them whenever feasible.

  • During such discussions, key topics should include prognosis, the patient's values, and the risks and expected outcomes of life-sustaining interventions.

  • Meetings to discuss prognosis require arranging a private interview, informing the patient to the extent they desire, offering empathic support, summarizing clearly, and discussing strategies to achieve goals of care.

  • Patients and their families should be advised that most patients who have an in-hospital cardiac arrest will not survive to discharge, and that many of those who do will have significantly decreased function.

  • The medical record should include clear documentation of goals-of-care discussions and decisions.

The guidelines authors have disclosed no relevant financial relationships.

CMAJ. Published online July 15, 2013.

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