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Tackling the Hardest Conversation a GP will have with a Patient – End of Life Care

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I can’t think of a more difficult conversation to have than discussing a patient’s end of life care with them. I’m fortunate that I won’t have to have this conversation until my own time comes. I can only imagine how hard it must be, and I’m not surprised that so many doctors shy away from the end of life talk.

In a 2014 survey in the United States, a third of doctors and nurse practitioners quizzed said they lacked confidence indiscussing end of life care. Only a shade more than one in ten said they routinely discuss end of life with heart failure patients on a yearly basis.

I’m not going to discuss in full the GMC guidelines with regards to treatment and care towards the end of life here. You’ll find a link to the GMC guidance at the end of this article. What I want to discuss here is a strategy that may help doctors and patients overcome their natural reticence to discuss end of life.

It’s as difficult for the patient as it is for you

A big leveller for doctors is when they realise that the discussion needed is a subject that is as hard for the patient to tackle as it is for them. We all know that we’re not immortal, and yet on the whole we don’t wish to discuss our death.

I recently read some advice that got me thinking how to tackle this difficult area. The trick is to help your patient ask the right questions. Give them the power, and help them understand that their care, treatment and dignity is in their hands; but for their wishes to be met, then the conversation has to be had.

Let your patient know about the guidelines on patient consent. When a patient understands that medication and treatment is now a joint decision-making process in which you and the patient collaborate towards the desired outcome, then it becomes easier for the patient to ask the questions needed.

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Encourage your patient to seek all the answers

Put yourself in your patient’s shoes. What would you want to know? If you bear in mind the questions that should be answered, then you can guide your patient through the discussion with compassion and understanding.

It may be that this patient appointment would be better conducted in the presence of another – a family member, friend, or other carer of the patient. Give them the option to make this happen. This third party will be able to offer further support to your patient, and provide a more informed sounding board away from the surgery.

The questions that need answering

During the conversation about end of life treatment, consider that you should cover all the following questions:

Condition:

- Is the disease curable?

- Will life be shortened? If so, by how long?

- How will the condition progress?

Advantages and disadvantages of treatment

- How will the treatment benefit my condition?

- Is the condition likely to return?

- Will the patient be able to function normally during treatment and after?

- What are the side effects?

- What about quality of life?

- Are there any activities that will need to be given up?

- How much time will be spent in hospital?

Other options available

- Are there any other treatments available?

- Could the disease be slowed rather than cured?

- Should comfort of the patient be the overriding factor?

- What about the option of doing nothing?

- Is care in a hospice an option?

Be prepared for the ultimate question

Even though you will have discussed how decisions are made together, and that ultimately it is the patient’s choice, you had best be prepared to answer the ultimate question that most patients will ask. You are a trusted member of the community. It’s likely that you have been treating your patient for years. Perhaps even since he or she was a child.

They’ll expect an answer when they ask you what you would do in their situation. And that may be the most difficult medical advice you’ll ever have to offer.

Download the GMC guidance: Treatmentand care towards the end of life: good practice in decision making

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If you have any questions or feedback, please do not hesitate to contact me -alex.henman@esuppliesmedical.co.uk- 01865 261451

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