Beyond advance directives: importance of communication skills at the end of life

Beyond advance directives: importance of communication skills at the end of life

Tulsky JA

Jama

2005

Communication; U.S. Gov't; PedPal Lit; Extramural Research Support; N.I.H.; Non-U.S. Gov't Research Support; Advance Directives Colonic Neoplasms/secondary/therapy; Decision Making Humans Interprofessional Relations Liver Neoplasms/secondary/therapy Male Middle Aged Palliative Care Pancreatic Neoplasms/pathology/therapy; Non-P.H.S. Research Support; P.H.S.Terminal Care; Physician-Patient Relations Research Support

Patients and their families struggle with myriad choices concerning medical treatments that frequently precede death. Advance directives have been proposed as a tool to facilitate end-of-life decision making, yet frequently fail to achieve this goal. In the context of the case of a man with metastatic cancer for whom an advance directive was unable to prevent a traumatic death, I review the challenges in creating and implementing advance directives, discuss factors that can affect clear decision making; including trust, uncertainty, emotion, hope, and the presence of multiple medical providers; and offer practical suggestions for physicians. Advance care planning remains a useful tool for approaching conversations with patients about the end of life. However, such planning should occur within a framework that emphasizes responding to patient and family emotions and focuses more on goals for care and less on specific treatments.

2005

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