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4 May 1999 | Volume 130 Issue 9 | Pages 744-749
Palliative care focuses on relief of suffering, psychosocial support, and closure near the end of life. Even experienced physicians often struggle when initiating complex, emotionally laden discussions about palliative care with seriously ill patients and their families. We use two hypothetical case scenarios to illustrate how physicians can initiate these discussions and to emphasize and illustrate several communication techniques.
Physicians can elicit a patient's concerns, goals, and values by using open-ended questions and following up on the patient's response before discussing specific clinical decisions. Physicians can acknowledge patients' emotions, explore the meaning of these emotions, and encourage patients to say more about difficult topics. Physicians should also screen for unaddressed spiritual and existential concerns. Some patients may make statements or ask questions that are difficult for physicians to respond to. We provide examples of responses that align the physician with patients' wishes without reinforcing unrealistic plans. Exploring such difficult issues may lessen feelings of aloneness even when the physician cannot "fix" the problem, and it raises new opportunities for patients to find comfort.
In addition to addressing physical suffering, physicians can extend their caring by acknowledging and exploring psychosocial, existential, or spiritual suffering. As patients struggle to find closure in their lives, active listening and empathy have therapeutic value in and of themselves.
Author and Article Information
This paper was written by Bernard Lo, MD; Timothy Quill, MD; and James Tulsky, MD, and was developed for the American College of Physicians-American Society of Internal Medicine (ACP-ASIM) End-of-Life Care Consensus Panel. Members of the ACP-ASIM End-of-Life Care Consensus Panel were Bernard Lo, MD (Chair); Janet Abrahm, MD; Susan Block, MD; William Breitbart, MD; Ira R. Byock, MD; Kathy Faber-Langendoen, MD; Lloyd W. Kitchens Jr., MD; Paul Lanken, MD; Joanne Lynn, MD; Diane Meier, MD; Timothy Quill, MD; George Thibault, MD; and James Tulsky, MD. Primary staff to the Panel were Lois Snyder, JD (Project Director); Jason Karlawish, MD; and Karine Morin, LLM. This paper was reviewed and approved by the Ethics and Human Rights Committee and the Education Committee. Members of the Ethics and Human Rights Committee were Risa Lavizzo-Mourey, MD (Chair); Joanne Lynn, MD; Richard J. Carroll, MD; David A. Fleming, MD; Steven H. Miles, MD; Gail J. Povar, MD; Susan H. Thompson, MD; James Tulsky, MD; Alan L. Gordon, MD; Siang Y. Tan, MD; and Lee J. Dunn Jr., LLM. Members of the Education Committee were Faroque A. Kahn, MD (Chair); Michael A. Ainsworth, MD; John B. Bass, MD; John R. Feussner, MD; Donald E. Girard, MD; John J. Hoesing, MD; Faith T. Fitzgerald, MD; Alphonso Brown, MD; Jerome H. Carter, MD; Sandra Adamson Fryhofer, MD; William J. Hall, MD; Rodney Hornbake, MD; Christine S. Hunter, MD; Mary E. Moore, MD; and Kurt Kroenke, MD. This paper was approved by the Board of Regents on 12 July 1998.
Acknowledgments: In part by the Greenwall Foundation, the Robert Wood Johnson Foundation, Center Grant MH42459 from the National Institute of Mental Health, and Career Development Award #97-316 from the Health Services Research & Development Service, Department of Veterans Affairs. Dr. Tulsky is a Project on Death in America Faculty Scholar and a Robert Wood Johnson Generalist Physician Faculty Scholar.
Requests for Reprints: Lois Snyder, JD, Center for Ethics and Professionalism, American College of Physicians-American Society of Internal Medicine, 190 N. Independence Mall West, Philadelphia, PA 19106.
Current Author Addresses: Dr. Lo: Program in Medical Ethics, University of California, San Francisco, Room C 126, 521 Parnassus Avenue, San Francisco, CA 94143-0903.
Dr. Quill: The Genesee Hospital, 224 Alexander Street, Rochester, NY 14607.
Dr. Tulsky: Durham Veterans Affairs Medical Center (11-C), 508 Fulton Street, Durham, NC 27705. ACADEMIA AND CLINIC
Discussing Palliative Care with Patients
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