The Meaning of Everything: Communication at the End of Life

Communication about end-of-life care is increasingly recognized as a core clinical skill, but doctors are often unprepared to have these conversations. Crisis situations at the end of life, such as when a hospitalized patient with a poor prognosis requests that “everything” be done, pose even greater communicative challenges. Such decisions are often regarded as a demand for care that may be burdensome or even harmful, rather than the start of an important conversation about values and goals. Situations such as this have prompted the development of prescriptive approaches to communicating with patients, which have limitations since they focus more on the physicians’ message than on developing a relationship with the patient or eliciting the meaning of the illness and its treatment. Current models of communication are less about accurate transmission of information and more about the ways in which communication constitutes our social world. Thus, the goal of communication training for physicians should be less about tools and scripts, and more about doctors learning to engage patients in conversation. We suggest strategies for promoting dialogue to more effectively explore the concerns and misunderstandings that might underlie decisions to “do everything.

Identifying a Proxy for Health Care as Part of Routine Medical Inquiry

BACKGROUND: Physician-initiated advance care planning is desirable, effective, and routinely indicated for competent adult patients, but doctors are often reluctant to begin the necessary conversations. OBJECTIVE: To determine whether patients are willing and able to designate a surrogate for medical decision making, when asked to do so as part of routine medical inquiry. DESIGN, PATIENTS, MEASUREMENTS: A survey asking patients to name a health care agent was designed and administered in the context of routine clinical care. Participants were drawn from a consecutive sample of 309 competent adult outpatients. Data were analyzed using ordinary descriptive statistics. RESULTS: Two hundred ninety-eight of 309 patients (response rate, 96%) completed the survey and were willing and able to specify a proxy for health care. One third of married participants did not choose their spouse as proxy. CONCLUSIONS: Asking patients to identify a surrogate for medical decision making opens the door for ongoing individualized medical care planning in the context of ordinary patient-physician interaction. This approach is applicable to all competent adults. Documenting proxy choice protects a patient's wishes and preferences until more definitive planning is accomplished