Being a Family Doctor is one of the most rewarding parts of my life. The word “family” is inherent in my work. I tend to care for people over their entire lives, across generations, becoming an observer and contributor to their health and wellbeing. I am a listening ear, a confidant, a sounding board, a giver of good and bad news, a trusted friend; someone that can and should have the tough conversations with a patient. I make deep and long-lasting relationships with patients, and there is an expectation to be honest, empathetic, caring, and genuine. They come to me because they trust that I will tell the truth and that my goal is for them to have long, healthy lives.
A hard truth I have come to realize is that we can only live for so long. That was a tough lesson for me in my career. As much as I want to preserve life for my patients, I will inevitably fail every one of them. Death happens for everyone, despite my best efforts. It seems counter intuitive to the goal of my work, prolonging life through medicine and scientifically backed advice.
Death is inevitable. However, the kind of death we have, can be managed. Our wishes about how we face our demise can be outlined. As a family doctor, I can have these conversations with my patients about their desires for end-of-life care and document those decisions in their chart. Patients want to have these conversations with their family doctors because the relationship is established. They feel safe opening up about their desires leading up to death.
The best time to have these conversations is when a patient is not actively dying. I tend to start during the Annual Well Visit. The well visit is a low stress appointment for both the patient and the doctor. The patient is well. I typically give more time at these visits, which allows for more conversation. I talk about diet, exercise, managing stress levels, as well as Advanced Care Planning. Advanced Care Planning is a patient-centered discussion that plans for future medical decisions. It outlines what care the patient wants, who can make those decisions on their behalf, and ensures that their future care is congruent with their personal goals and values.
What kinds of questions should we be asking the patient when it comes to Advanced Care Planning? What is the information that we want to elicit? The most important thing to keep in mind is that there is no one way to do this. We will all approach this differently based on our comfort level and experiences. It is going to be awkward, especially if you have never had these conversations before. I usually start by acknowledging that the conversation is not easy for me, but I know it is important and meaningful to the patient. Patients appreciate the honesty. Being upfront about my own discomfort about discussing desires for end-of-life care diffuses the situation. It’s uncomfortable for everyone. It does get easier, especially when a patient has their desires heard and honored, and you were the catalyst for that. Some questions to consider:
- What is your understanding of your health or current illness?
- What are you most important health-related goals?
- What does a good day look like for you?
- What brings value to your life?
- What are your fears or worries regarding your health?
- What are the trade-offs you would be willing to make (or not make) if your condition worsened?
Once the conversation has been started, I encourage the patient to formalize their wishes. By putting their wishes down on paper, it creates a framework for family members and healthcare providers to follow when the patient is facing end of life. This can be done in several ways:
- MOST (Medical Orders for Scope of Treatment) Form
- Advanced Directives
- Durable Health Care Power of Attorney (can include a Living Will)
Each state has specific rules regarding documentation of end-of-life care. You can find the most up to date information on the Advanced Directive Forms for your state at the National Institute on Aging website.
In general, patients can fill these forms out without a lawyer. Some of these forms (depending on the state) do require a notarized signature.
I think it is important to start these conversations early. It gives the patient time to consider their own wishes, have conversations with their family, ask questions about scenarios they may encounter in their healthcare, and become comfortable with the notion of preparing for end of life. It gives them a sense of control, it gives their family peace of mind, and it gives the provider a better understanding of their patients’ values and desires. Consider starting the conversations about Advanced Care Planning today.
In the next article (and final), I will discuss coding and billing for conversations with our patients about Advanced Care Planning.