End-Of-Life, Palliative-Care Discussions Are Hard, Even For Doctors

Death Talks
Patients who want to discuss death with their doctor may find the topic difficult for both sides to broach. Photo courtesy of Adam Berry/ Getty Images

Death is a looming and ominous topic of conversation to broach for most people, and according to a nationwide poll, doctors are no different. As America’s aging population grows to unprecedented numbers, doctors will have to prepare for more end-of-life conversations in order to plan for their patients’ futures.

The poll, conducted by The John A. Hartford Foundation, asked 736 primary care doctors and specialists how they felt about having one-on-one conversations about advance care for end-of-life situations with their patients. A large majority of the doctors (roughly 75 percent) believe it’s their responsibility to initiate the end-of-life conversations, however, less than one-third have received training on how to do so effectively with their patients and patients’ family members.

Seventy-five percent of the doctors say the conversations, which are often held in a hospital or other healthcare facility, are initiated because Medicare (government-funded health insurance for the elderly) reimburses for advanced-care planning. However, only approximately 14 percent of the doctors report having to bill Medicare-eligible patients for having the conversations. Despite the fact that end-of-life talks are covered by insurance for elderly patients, which removes financial hurdles, doctors still find it difficult to overcome the discomfort of talking about death. More than that, most electronic paperwork systems are so antiquated, doctors report there’s no place to include their patients’ end-of-life preferences in their file.

End-of-life conversations not only help ensure a patient the specific type of treatment they want once they may no longer be able to articulate their desires, but they also save costs associated with treating someone medically who doesn’t want to prolong life. Without “the talk,” doctors and possibly even family members would be left in the dark on how their loved one wishes to finish out life.

Unfortunately the quality and quantity of conversations aren’t meeting the needs of patients, who more and more want to discuss their plans but don’t know how to initiate the conversation. According to survey results published in PLOS One in 2015, patients typically wait for their doctors to take the reins and are left with no plan in the end. But according to the poll, more than half of the doctors surveyed said they haven’t even discussed end-of-life care with their own doctors.

By 2050, the world’s elderly population is predicted to double, according to a recent report published by the United States Census Bureau and the National Institute of Aging. Palliative care, the field of specialized medical care for people with serious and often life-threatening illnesses, may need to evolve to better serve the growing elderly population.

“We need an infrastructure dynamic enough to handle these seismic shifts in our population,” palliative care physician Dr. B.J. Miller, who is also the executive director at Zen Hospice Project in San Francisco, said in a Ted Talk. Now is a time to create something new, something viable. I know we can because we have to. We know, for example, from research what’s most important to people who are closer to death: comfort, feeling unburdened and unburdening to those they love, existential peace, and a sense of wonderment, and spirituality.”

While death remains an inevitability for everyone, Miller says it’s the dying that people fear most — not death itself. At the end, patients fear the unknown, which is why putting a plan into place that can be easily acted upon is a powerful tool to ease those fears. 

Source: Conversation Stopper: What’s Preventing Physicians from Talking with Patients About End-of-Life and Advance Care Planning? The John A. Hartford Foundation . 2016.

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