Intended for healthcare professionals

Views And Reviews

Yes, doctors need to talk about dying, but what if patients start the conversation?

BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4648 (Published 05 November 2018) Cite this as: BMJ 2018;363:k4648
  1. Mark Taubert, consultant in palliative medicine, honorary senior lecturer, strategic lead for advance care planning12
  1. 1Cardiff University School of Medicine, Wales, UK
  2. 2Wales, UK
  1. mtaubert{at}doctors.org.uk
    Follow Mark on Twitter @DrMarkTaubert

A recent report called on doctors to initiate conversations about dying earlier on in a patient’s illness trajectory. Mark Taubert describes how patients are key to improving this

I was talking to Neil, an IT worker in his 50s with advanced cancer, about his wishes for when things got worse over the coming year. What would he want medics to try if he was unable to communicate; were there any interventions he’d want to forgo? Neil and I had never met before and already we were talking about the big taboo topic: our dying moments and death.

A recent report by the Royal College of Physicians highlighted how doctors struggle with talking about dying, making them reluctant to broach the subject with patients. It concluded that many people are so focused on the benefits of modern medicine that talking about the inevitable—dying—seems like an unpleasant distraction, a waste of time.

Doctors and nurses can be willing colluders in patients’ and their families’ narrative (“Let’s fight this and beat cancer”). Some patients may even feel that talking about death and dying implies that a doctor knows something they don’t.

I’ve often been mildly apologetic when I start talking about advance care planning and what lies ahead, but acknowledging this is sometimes a good way in: “I’m sorry to bring something up that may seem a bit alien—especially since you’re feeling better at the moment—but have you thought about what you’d like to happen, and not happen, when you get very unwell in the future?”

When I raised this with Neil, he understandably needed time to think things through and talk with his family—these conversations often don’t take place in just one sitting. Neil had questions about what each intervention might do and what the pros and cons were. We talked; I gave him my views and a video about cardiopulmonary resuscitation.

My patients and their loved ones react quite differently to this kind of conversation. It must feel like the rug is being pulled out from under you. But then has society not informed this reaction? If so, then perhaps a societal change in attitude can help.

I spoke to our hospital’s patient and carer liaison group recently, and one of them believed that the taboo around this conversation may be decreasing. She felt that patients and their families can be well placed to turn the tables on their doctor and ask the question themselves: “Can we talk about dying?”

I hope that the report by the Royal College of Physicians, with its recommendations for doctors and other healthcare practitioners on how best to begin this conversation, starts a separate debate on whether patients can bring this up with their doctor. Twitter has been very vocal on this topic recently, with many patients recounting how they took control of the consultation.

When Neil came to the hospital after my initial chat, he had made up his mind. He saw a different doctor who later came to me and said he was taken aback by Neil’s frankness and expertise on this topic. “I thought he wanted to chat about chemo. He did, but he also said that he wanted a DNACPR (Do not attempt cardiopulmonary resuscitation) form filling in and he talked about where he wants to spend the last days of his life. It thrust me into a conversation I don’t often have. But it was good.”

Perhaps, when patients turn the tables on doctors and start the advance care planning discussion themselves, we will see the start of a change in culture. Until then, doctors must do all that we can to find good ways of starting compassionate, but realistic, conversations about serious illness.

Footnotes

  • Patient consent not obtained as the patient died a few years ago. His name has been changed.

  • Competing interests: None declared.

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