Sometime ago Don Berwick, MD spoke about 20 improvements that doctors could make in the end of life care of their patients that begins in a simple conversation. Berwick recommended the following considerations as his top three suggestions:
- Ask yourself as you see patients, "Would I be surprised if this patient died in the next few months?" For those "sick enough to die," prioritize the patient's concerns - often symptom relief, family support, continuity, advance planning, or spirituality.
- To eliminate anxiety and fear, chronically ill patients must understand what is likely to happen. When you see a patient who is "sick enough to die" - tell the patient, and start counseling and planning around that possibility.
- To understand your patients, ask (1) "What do you hope for, as you live with this condition,"(a) "What do you fear?," (b) It is usually hard to know when death is close. If you were to die soon, what would be left undone in your life?," and (4) "How are things going for you and your family?" Document and arrange care to meet each patient's priorities.
All too often the task of finishing the business of living gets left undone because the end of life conversation has never taken place for whatever reason. A referral to the Clinical Chaplain would of course be an appropriate action in the hospital setting.