When should doctors talk about death?

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Doctors should discuss end-of-life issues with their patients when they are terminally ill with less than one year to live, according to formal recommendations. But many doctors are reluctant to initiate such talks until patients are late in the course of the illness, according to a new study.

End-of-life issues include such important points as prognosis and preferences for resuscitation, hospice care and where patients would like to die. Some studies suggest that people who have these discussions with their doctors have better experiences with death. Researchers led by Dr. Nancy Keating at Brigham and Women’s Hospital and Harvard Medical School surveyed 4,074 doctors about end-of-life discussions with cancer patients who had four to six months to live but were currently feeling well.

Only 44% of the doctors said they would be willing to discuss resuscitation while the patient was still feeling well and only 26% would discuss hospice. Instead, they would wait until patients felt worse or no more treatment options were available. The study is published online today in the journal Cancer.

It could be that doctors don’t want to bother with difficult and time-consuming end-of-life discussions when there is still time left to talk about these issues later. Or it could be doctors disagree with the recommendations to initiate such discussions. Moreover, little is known about patients’ preferences regarding the timing of these discussions. Some studies show patients think doctors are giving up on them if they raise end-of-life issues. Others say they would prefer that doctors are candid and give them and their families plenty of time to plan.

The dilemma for doctors is obvious. But patients can take matters into their own hands by initiating the discussion. Plenty of materials are available to help people who are terminally ill and their families prepare. See:

• HospiceNet.
• ‘End-of-Life Care: Questions and Answers,’ from the National Cancer Institute.
• Journal of the American Medical Assn: ‘Decisions About End-of-Life Care,’ American Medical Assn.
• ‘Talking About End-of-Life Treatment Decisions,’ Agency for Healthcare Research and Quality.
• ‘End of Life: Helping With Care and Comfort,’ National Institute on Aging.

-- Shari Roan