Barriers to talking about dying

A NEW report highlights a feeling among some physicians that death could be perceived as a "medical failure" and this constitutes a barrier to talking with patients about dying.

The report from the Royal College of Physicians (RCP) states that it is vital that doctors and other healthcare professionals have the knowledge, skills and confidence to undertake sensitive conversations at an appropriate time when dying patients are ready.

Talking about dying: How to begin honest conversations about what lies ahead is based on conversations with doctors at all levels, patients/carers and medical organisations, and it reveals the barriers that stand in the way and offers solutions and resources to help, including a ‘mythbusting section’ debunking common but erroneous beliefs.

Among the barriers to talking about dying identified in report are "cultural" factors, with some physicians feeling that death could be perceived as a failure and that modern medicine is expected to cure all ailments. The report states that the evidence from patients and carers is that many do want to talk about death and planning helps patients feel more empowered about care and decision-making.

The report also cites a lack confidence, with many doctors uncomfortable initiating conversations about the future with patients. Medical students and junior doctors have little practice with real patients and training does not prioritise the ‘soft’ skills needed. Diagnostic uncertainty was also often an issue.

There is also confusion over whether hospital doctors or the patient’s GP should be having the conversation and a reluctance to begin such conversations when the doctor may not be responsible for the patient’s care going forward. Workforce pressures, lack of privacy or prioritised clinics or ward time to have the conversations, and the challenges of being sensitive to different cultural and religious beliefs were also cited as challenges.

The report makes a series of recommendations for physicians and the wide healthcare system to improve the situation, including:

• Ask the patient if they would like to have the conversation and how much information they would want.
• All healthcare professionals reviewing patients with chronic conditions, patients with more than one serious medical problem or terminal illness should initiate shared decision making, including advance care planning in line with patient preferences.
• Conversations about the future can and should be initiated at any point, the conversation is a process not a tick-box, and does not have to reach a conclusion at one sitting.
• Be aware of the language you use with patients and those they have identified as being important to them; and try to involve all the relevant people in agreement with the patient.

RCP president Professor Andrew Goddard said: "This report is a big step forward in helping patients, relatives and doctors to talk honestly about death and dying. We must minimise the barriers in our systems and culture that prevent this from happening. This is not just about palliative care in the final days, but about having a series of conversations much earlier after a terminal diagnosis."