EOL Discussions – Dos and Donts

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KONICA MINOLTA DIGITAL CAMERA

DON’T

1. Begin the discussion about treatment options
2. Don’t be preoccupied with what is on your agenda or what you believe or don’t believe you should offer
3. Assume the patient or relatives understand the implications of their illness
4. Ask ‘Do you want us to do everything’
5. Use the words ‘futile treatment’
6. Talk in absolutes e.g ‘no chance’, ‘won’t survive’
7. Use  crass phrases ‘jump on chest’, ‘break ribs’,  ‘shock the heart’
8. Feel obligated to go into excruciating detail about every type of medical intervention possible
9. Focus on potential benefits without speaking about potential risks or harms
10. Be vague about the situation or the prognosis
11. Appear to rush the process

1. Focus on the patient’s experience of their illness
2. Be frank and honest about the state of someone’s acute or chronic illness and overall untreated and treated prognosis
3. Relate disease and daily function
4. Be prepared to use the term ‘dying’ or ‘likely will die’
5. Centre the discussion around personal values and quality of life
6. Contextualise the discussion of values back to the potential of imminent life-threatening illness or death.
7. Put short-term prognosis in the context of mid to long term prognosis
8. First talk in generalities of a continuum of minimally-invasive therapies with low discomfort to highly-invasive therapies with unavoidable high discomfort
9. Reinforce that it is a combination of patients wishes, comfort and dignity that guides any decision
10. Reassure that withdrawal of treatment is not the same as withdrawal of care or symptom control
11. Verify everyone’s understanding
12. Give space to the patient and loved ones to digest the discussion before requesting a response

• always hope that death comes swiftly and painlessly and consequently avoid EOL decisions
• may not anticipate or conceive that death follows a brief period of acute illness
• may feel guilty of accelerating death by withholding treatment but do not know that providing treatment may increase suffering
• do not tolerate uncertainties or probabilities and have an unrealistic need for definitive answers
• may minimise the amount of discomfort or suffering during a chronic illness
• are often confused about what is involved in medical care
• may focus more on the potential benefits of life-saving care rather than its likelihood of benefit or more importantly likelihood of harm
• do not understand the implications of invasive medical interventions e.g. CPR, intubation, mechanical ventilation, dialysis
• do not factor in the impact of convalescence from acute illness on quality-of-life