How physicians are learning to talk to patients about dying

A conversation guide is helping physicians learn strategies for some of the most difficult discussions they have as care providers — telling patients they are dying.

Physicians can be so focused on trying to fix each ailment that "no one is addressing the big picture," particularly when addressing patients who are dying, said Lynn Black, MD, a physician at Boston-based Massachusetts General Hospital.

Dr. Black, along with hundreds of other physicians at Massachusetts General Hospital, are now receiving training to talk seriously with ill patients about their goals, values and prognoses. To practice these conversations, physicians use a script based on the Serious Illness Conversation Guide.

The guide has trained more than 6,500 clinicians across the globe since its 2012 inception, said Rachelle Bernacki, MD, associate director of the Serious Illness Care Program at Ariadne Labs in Boston.

Juliet Jacobsen, MD, a palliative care physician at Mass General, serves as medical director for the Continuum Project, which works to quickly train clinicians to navigate through these conversations.

To help physicians begin these discussions, Dr. Jacobsen gives them a laminated page with scripted language. The participants engage in role playing with professional actors, where they tend to quickly experience communication difficulties. To solve these difficulties, Dr. Jacobsen encourages physicians to allow more silence and respond to patients' emotions rather than only their words.

The scripted conversation is significantly different from how physicians have been trained to talk with patients, Dr. Jacobsen acknowledged. However, the script does not intend to reach any decision or complete end-of-life paperwork.

Rather, the scripted conversations serve as a way for physicians to step back from day-to-day problem solving and discuss the patients' understanding of their illness, their hopes and worries and their disease trajectory.

Dr. Jacobsen's team suggests physicians use compassionate language to discuss a prognosis without asserting certainty. Some examples include saying, "I worry the decline we have seen is going to continue," or, "I worry something serious may happen in the next few months."

The team plans to follow up with physicians after the training to ensure they are having these conversations with patients, beginning with patients who have been deemed likely to die within three years.

Dallas-based Baylor Scott & White Health, Lowell (Mass.) General Hospital, Philadelphia-based University of Pennsylvania and hospitals in 34 foreign countries are also beginning to roll out the conversation guide, Dr. Bernacki said.

"Our goal is for every patient with serious illness to have a meaningful conversation about what they care about, in every place," Dr. Bernacki said.

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