Talking about Difficult Things

These are discussions most physicians avoid like contagion: talking to patients about illness and dying. Once we doctors “go there”,  we’re on uncertain ground. While we learned to do a physical exam, start an IV, intubate and take a clinical history in our training, most of us haven’t learned the delicate dance of an end-of-life conversation.

What I am learning at a Palliative Care course at Harvard this weekend is how to execute this dance without sending the patient spinning off the stage (and without tripping over my feet).

There are some pretty simple tools to use. I particularly like the question “What is your understanding of your illness?” I’m afraid most of us never ask that directly, relying instead on some pretty shaky assumptions.

I am struck that the skills I am learning will apply to conversations with patients at all stages of life…and convinced that all physicians should get this kind of training. For example, I’ve seen many patients who aren’t actively dying, but are struggling with chronic conditions that are slowly sapping them of life and/or the will to live. Asking them about their hopes and fears may lead to a breakthrough understanding of their condition. As one of my favorite doctors once put it: “The goal in medicine should not just be about solving the puzzles, we’ve got to want to unlock the mysteries.”

Further, whether you are an ER physician, primary care doctor, surgeon, anesthesiologist, radiologist or dermatologist…you will inevitably encounter a terrified patient who asks: “Doctor, am I going to die soon?” All of us who don white coats should have a strategy to answer that question-or pose another one, such as: “What are your greatest fears around this illness?” Engaging people in this dialogue distinguishes us as doctors, even when we can’t offer a cure.

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