Difficult conversations: When a patient is facing death

By Kay Torrance | Woodruff Health Sciences Center | July 15, 2014

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Through role playing and expert coaching, new doctors are becoming more skilled in having difficult conversations with patients’ families.

Palliative Care Center Director Tammie Quest, an emergency medicine physician, is coaching a group of fourth-year medical students on how to have difficult conversations with patients' families about their medical condition.

It's all part of prepping these soon-to-be physicians in the art and science of palliative care, a burgeoning subspecialty that focuses on providing patients relief from symptoms of serious or life-threatening illness.

As residents, most of them will be called on to lead such meetings, which are difficult even for seasoned physicians, Quest concedes. Many doctors now call Emory's palliative care physicians to handle the uncomfortable task. "That's why we have 6,000 palliative care consults each year," she says. "We're often called to pick the family up off the floor after a diagnosis has been made. Family meetings will come to you over and over in your career."

Quest has spent her career perfecting the language she uses to converse with families, and teaching others how to do the same. She became interested in palliative care after graduating from medical school at UC–San Francisco and realizing that no one had versed her in how to tell someone that their family member had died.

"In medicine today, we've moved away from the idea that good communication skills are inherent—that because you are a kind, sensitive person you must be a good communicator," she says. "Now there is a fundamental belief in medicine that communication skills are not inherent, they are taught."

Quest started the first palliative care service at Grady Hospital in 2005 and is director of the Emory Center for Palliative Care, formed in 2010 to integrate palliative care across Emory Healthcare and its affiliates, and to foster research in the field. The center now has palliative care programs in five Emory or Emory-associated hospitals and has received $4.2 million in research funding.

Numerous studies have pointed to better outcomes for patients under palliative care—they often undergo fewer aggressive and expensive treatments, yet have longer survival times. In one three-year study at Massachusetts General Hospital, advanced lung cancer patients were randomly assigned to either standard oncology care or standard oncology care and palliative care. The palliative care patients had fewer symptoms of depression and a 2.5-month longer median survival rate.

Palliative and hospice (end-of-life) care are slowly making inroads as medical centers look to reduce costs in the wake of health care reform. Today 33% of hospitals have a palliative care program. The bigger the hospital, the more likely it is to offer palliative care—80% of hospitals with more than 300 beds have such programs. The field began forming in hospitals about 20 years ago and became an official subspecialty of medicine in 2008. Still, confusion persists. "Not all physicians separate palliative care from hospice care, but when they understand our role they will work with us," says Emory palliative care physician Alyssa Majesko. "We are a consistent face in an often overwhelming system."

Palliative medicine is integrating into the fabric of medicine, Quest says. Nursing, social work, and chaplaincy have already embraced palliative care concepts, and even emergency departments are using palliative care services. Emory, for example, began screening all cancer patients who come into the ED for palliative care needs in 2009.

"During the past century of therapeutic advances and training paradigms that codified a never-give-up ethos, we lost some of the compassion of medicine," says School of Medicine Dean Chris Larsen, who is also a transplant surgeon. "Tammie and the palliative care team's efforts are helping us reclaim this vital aspect of patient-centered care."

Back in patient exam training rooms on the third floor at the School of Medicine, fourth-year students are practicing talking to actors who are playing the role of a patient's family member. One group is holding a "family meeting" with the wife and son of a 60-year-old man who suffered cardiac arrest and whose condition is declining. "Sometimes we can hedge and be more optimistic when we don't know the answer to a family's question. First-year residents often hedge. Don't hedge," Quest counsels.

Being clear and straightforward, however, doesn't mean being insensitive or destroying hope.  "We are teaching empathic communication," she says, "not blunt or overly direct communication."

Another group must ask the family if they want to institute a do-not-resuscitate order. One student starts to say, "What do you want us to do if…" and then backtracks, having already been advised by Quest to avoid that phrase, as it has no context.

Doctors, Quest says, are there to make an assessment and recommendations.

"As physicians, we have a hard time living in the gray, where things are not settled," Quest says. "Three-fourths of palliative care is about the phrases you use. The hardest part is getting the language correct."