Developing accurate prognostic awareness, a cornerstone of preference‐based end‐of‐life (EOL) care decision‐making, is a dynamic process involving more prognostic‐awareness states than knowing or not knowing | The Oncologist
Understanding the transition probabilities and time spent in each prognostic‐awareness state can help clinicians identify trigger points for facilitating transitions toward accurate prognostic awareness. We examined transition probabilities in distinct prognostic‐awareness states between consecutive time points in 247 cancer patients’ last 6 months and estimated the time spent in each state.
Terminally ill cancer patients’ prognostic awareness generally remained unchanged, with a tendency to become more aware of their prognosis. Health care professionals should facilitate patients’ transitions toward accurate prognostic awareness in a timely manner to promote preference‐based EOL decisions.
Terminally ill Taiwanese cancer patients’ prognostic awareness generally remained stable, with a tendency toward developing higher states of awareness. Health care professionals should appropriately assess patients’ readiness for prognostic information and respect patients’ reluctance to confront their poor prognosis if they are not ready to know, but sensitively coach them to cultivate their accurate prognostic awareness, provide desired and understandable prognostic information for those who are ready to know, and give direct and honest prognostic information to clarify any misunderstandings for those with inaccurate awareness, thus ensuring that they develop accurate and realistic prognostic knowledge in time to make end‐of‐life care decisions.
Full reference: Hsiu Chen, C. et al. (2017) Transitions in Prognostic Awareness Among Terminally Ill Cancer Patients in Their Last 6 Months of Life Examined by Multi‐State Markov Modeling. The Oncologist. Published online before print: 6th July 2017.
Doctors don’t like to lose but she tells me she is ready to go. Now it’s important to maintain her comfort and dignity | The Guardian Healthcare Network
Mrs S is 93 years old and has severe pneumonia. She is sitting up in bed, with a big unwieldy mask strapped to her nose and mouth like a facehugger from Alien. This device is all that keeps her from lapsing into a coma. I sit at her bedside. We have just met. I am here to talk to her about her death.
As the medical registrar for a big hospital, I am often called in to help by other specialties when trouble arrives. Some days, by the time I’m summoned, trouble has already got its feet under the table. On rare days, I really am there to save lives. Other days, I feel like the grim reaper, stalking the halls like death in a pencil skirt.
As our knowledge continues to advance, and the menu of available treatments continues to expand, we can do more and more to keep people alive. But every day in hospitals up and down the country, the debate continues to rage as to what we should do. It’s a discussion that sounds like it should have a simple answer. Patients want to live; families want to do their best for their loved ones; doctors don’t like to lose and it’s easy to default to a “Do everything that you can” mindset.
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Talking about death and dying can be uncomfortable. But, the reality is that all lives end. Options and choices regarding end-of-life care have recently received scrutiny in the media, popular culture, academia and in the UK parliament, as well as devolved governments. Views are often polarised and debates elicit a range of responses. The issues are complex and nuanced and need to be explored in some depth in order to examine and understand them properly.
For all these reasons, the BMA launched a major project in November 2014 to examine both the public and medical professionals’ attitudes on aspects of end-of-life care and physician-assisted dying.
We wanted to explore:
- how the reality, and perceptions, of end of life care compare to models of good practice;
- the challenges of providing good care at the end of life; and
- the possible impact on the doctor-patient relationship if physician-assisted dying were to be legalised.
We believe the outcomes and recommendations from this project will help inform our own decisions and deliberations and also contribute to the broader public debate, now and into the future.
It is important to be clear that the project was not intended to alter current BMA policy on end-of-life care or physician-assisted dying, but to help facilitate a full and informed debate on the issue.
Volume 1: Setting the scene
Volume 2: Public dialogue research
Volume 3: Coming soon
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Read the full report via BMA
Joel D. Marcus and Frank E. Mott. Difficult Conversations: From Diagnosis to Death.The Ochsner Journal: Winter 2014, Vol. 14, No. 4, pp. 712-717
Although many published guidelines address difficult communication, communication training is lacking. Consequently, many clinicians may have difficulties with, or in the worst-case scenario, avoid delivering bad news and discussing end-of-life treatment. Clinicians also struggle with how to have the last conversation with a patient and how to support patient autonomy when they disagree with a patient’s choices.
There is a clinical imperative to educate physicians and other healthcare workers on how to effectively deliver information about a patient’s health status, diagnostic avenues to be explored, and decisions to be made at critical health junctions. Knowing how to implement the most rudimentary techniques of motivational interviewing, solution-focused brief therapy, and cognitive behavioral therapy can help physicians facilitate conversations of the most difficult type to generate positive change in patients and families and to help them make decisions that minimize end-of-life distress.