Palliative Care: Four Points to Improve Discussions About Dying

In an editorial appearing in the October 25 issue of The New England Journal of Medicine, medical oncologists at Johns Hopkins and Brigham and Women’s hospitals provide a four-point plan for integrating palliative care discussions throughout the treatment of patients with terminal illnesses. They write that better planning and communication may improve symptoms, stress, and survival time, as well as lower health care costs at the end of life. The two physicians suggest that their colleagues should discuss palliative care with patients during initial talks about prognosis at the first physician visit. This should be followed by further discussion about advance directives and hospice information (within the first three visits), and additional discussions of prognosis and coping (during periods when treatments change). “Physicians are not as forthright as we should be with patients about their prognosis,” says Thomas J. Smith, M.D., The Harry J. Duffey Family Professor of Palliative Medicine, professor of oncology, and director of Palliative Medicine at Johns Hopkins. “We do a fair job of communicating to patients that their terminal illness is incurable, but only one-third of doctors tell patients their prognosis at any time during their care.” A reason for this, Smith says, could be that doctors are afraid such discussions could take away a patient’s hope. “What they don’t realize is that hope is impossible to extinguish, and palliative care discussions can help patients focus on a better quality of life,” regardless of prognosis, he adds. Palliative care is defined as treatment designed to set medically appropriate goals, comfort, manage symptoms, and ease pain, rather than cure the disease. Smith’s editorial, written with Dan L. Longo, M.D., of Brigham and Women’s Hospital, accompanies a report of a study by a team of oncologists at Harvard’s Dana Farber Cancer Institute which finds that most patients with metastatic lung or colon cancer and a poor prognosis believe treatments were “likely to cure them.” “We have to do a better job of helping patients plan their remaining lives,” says Smith, who adds that studies on lung cancer show improved quality of life, quality of care, and survival for patients who received palliative care. Smith also suggests that patients who receive palliative care may have fewer unmanaged symptoms and access to additional health care staff who provide advice and resources. This additional level of care, Smith says, may reduce hospital readmission rates, and thus, overall health care costs. He adds that an important part of integrating palliative care is teaching health care providers ways to communicate issues surrounding end-of-life care. “Discussions with patients about how they are coping with their prognosis are not simple or easy,” Smith says. “But we can begin by asking patients and their families what they want to know about their prognosis and doing this at each transition point in their care.”