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April 29, 2019

The critical first step in end-of-life conversations, according to this Cleveland Clinic doctor

Daily Briefing

    Having end-of-life conversations with patients is never easy, but learning more about patients' priorities and lives outside of the hospital can make the difficult moments go a bit smoother, Mikkael Sekeres, director of the leukemia program at the Cleveland Clinic, writes for the New York Times' "Well."

    Download URMC's question prompt list to start improving end-of-life care for patients

    Unfamiliar territory

    In the Times, Sekeres recalls a medical student who requested to shadow him on daily rounds with leukemia.

    "I am going into surgery and feel underprepared in managing patients with terminal diagnoses," the student said in the email. "I was hoping to spend this elective learning about this as it would be useful to my career in the future."

    According to Sekeres, the email got his attention because the student was requesting to spend his final year of medical school "taking care of patients who would never be a part of his future practice." Surgery, Sekeres explained, generally is not considered an effective treatment for leukemia because bone marrow cannot be removed with a scalpel. Regardless, "I invited him to join me," Sekeres writes.

    Getting to know the patients

    For the next month, the student followed Sekeres and his team during rounds.

    When Sekeres asked the student what he hoped to gain from the rotation, the student said he'd "like to get better at giving bad news to patients," but offered no insight into the experience that prompted this desire.  

    So Sekeres gave him an assignment: "See if you can learn at least one fact about each patient's life outside of the hospital by what you observe in their rooms."

    For the next few days, the student continued to follow Sekeres and his team during rounds, "listening intently" to the conversations they had with patients. After rounds, Sekeres and the student would discuss what he learned about the "patients' lives outside of the hospital, their families, and their goals," Sekeres writes. One day, Sekeres asked the student about a patient in his 70s who had just received chemotherapy.

    "He worked as a machinist. And he has a girlfriend," the student said. The student also knew that the patient had a daughter who lived in California, but he'd never met or seen a picture of the daughter or the girlfriend.

    "Sounds like we need to figure out who's supporting him through this," Sekeres said.

    Having the 'difficult conversation'

    Eventually, Sekeres writes it was time to have the "difficult conversation" with the 70-year-old patient, his daughter, and his girlfriend: The patient's leukemia had returned and he was staying in the intensive care unit and required a breathing machine. Ultimately, the family and the patient decided to pursue palliative care and he died shortly after.

    When the student's training concluded, he confided in Sekeres about why he was so uneasy about delivering bad news to patients.

    During his surgery rotation, the student explained, his team treated a man who had pancreatitis and other infections in his abdomen. Eventually, the man became too sick to operate on, and when they told his family they got angry. "'We were really taken by surprise,'" The student told Sekeres. After a short pause, Sekeres writes that the student's eyes became "almost revelatory," and the student added, "'But I guess we didn’t know anything about his expectations, or theirs. Come to think of it, we didn't even know their names'" (Sekeres, New York Times, 4/24).

    Next, get URMC's end-of-life conversation prompts

    When it comes to end-of-life care, most organizations struggle to meet patients' needs. In a recent poll, 87% of Americans age 65 and older said that they believe their doctor should discuss end-of-life issues with their patients; however, only 27% of those polled had actually discussed these issues with their doctor.

    Download URMC's conversation prompts to start improving end-of-life care for patients.

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