Our medical training includes several years of learning diseases and how to treat or cure them. Our entire goal is to treat the patient and the disease. We spend several thousands of dollars diagnosing a problem, just so we can find the right care plan. But we are not taught how to let go and stop. We have minimal exposure to end-of-life care in our last 2 years of medical school, but we don’t have any formal training. Then we enter residency and suddenly face the fact that we can’t cure everyone.
End-of-Life Care is Just as Important as Life-Saving Treatments
Learning to recognize that it is important to let patients die with dignity, pain-free, and on their terms does not come easily. It isn’t something we like to do, but the reality is that everyone will die at some point.
Accepting that nothing else can be done is hard, but not as difficult as saying “Yes, there are other treatments. But those treatments will not prolong life and will likely cause more stress and pain.” These are difficult situations that patients, families, and physicians have a hard time with. Expressing this effectively so that patients don’t feel they are just giving up, or that families are killing their loved ones, is complicated and difficult.
As physicians, it needs to be part of our training to see this conversation happen and learn how to express this compassionately and effectively. We don’t need to convince anyone of what we know, but we do need to be able to tell them what we actually expect with further treatment. This includes the pain, the stress, and if it will provide any meaningful prolongation of life. We need to learn to educate our patients and family about the pain and lack of success that comes from performing CPR and advanced life support.
Learning to Say Stop
As physicians, we have a hard time stopping. We perceive a death as failure. A patient’s death is a mistake we made or a lack of ability. This is just not the case. Dying comfortably is a top priority for most patients.
I don’t have a quick answer on how to learn this skill. This requires exposure to hospice and palliative care medicine. You need to be open to the idea that allowing a patient to die comfortably is proper care and is a success, not a failure.
Defining Goals of Care Early
Start discussing the goals of care in the outpatient setting, long before a terminal diagnosis is made. We need to encourage the use of Advanced Directives when a patient is young and healthy. This allows us to comply with a patients wishes when they aren’t able to communicate them to us. It also allows the family to not have the burden of making end-of-life decisions in a highly emotional time. It prevents families from arguing about what they think the patient would have wanted. When the decisions are made, the tension, stress, and guilt are taken off the family.
Expose yourself to end-of-life medicine and goals of care early in your career. Accept that death is a part of our job and should be treated appropriately.