The Royal College of Physicians (RCP) latest report, Talking about dying: How to begin honest conversations about what lies ahead, explores the reasons that doctors and other healthcare professionals find it hard to talk to patients about dying.
Based on conversations with doctors at all levels, patients and carers, and medical organisations, the report reveals the barriers that stand in the way and offers solutions and resources to help, including a ‘mythbusting section’ debunking common beliefs surrounding the subject. Particularly in social care, the way care professionals approach the end-of-life care process is important for the individual, their family and carers. This is why programmes such as the Gold Standards Framework and Preferred Priorities for Care are recommended for settings in a bid to improve communication at every level.
Four English hospitals leading the way in supporting end-of-life care conversations have contributed good practice case studies to the report.The barriers to talking about dying identified by doctors include:
• Culture - Some physicians felt that death could be perceived as a failure and that modern medicine is expected to cure all ailments. However, the evidence from patients and carers is that many people do want to talk about death and planning helps patients feel more empowered about care and decision making.
• Confidence - From medical students to consultants, there were many doctors who felt uncomfortable initiating conversations about the future with patients; medical students and junior doctors had little practice with real patients; training doesn’t prioritise the ‘soft’ skills needed; and diagnostic uncertainty was often an issue.
• Practicalities - Confusion over whether hospital doctors or the patient’s GP should be having the conversation; reluctance to begin conversations when the doctor was not going to be responsible for the patient’s care going forward; workforce pressures; lack of privacy; lack of prioritised clinic or ward time to have the conversations; and the challenges of being sensitive to different cultural and religious beliefs.
One of the major issues identified in the report is that healthcare professionals need to begin conversations about planning for end-of-life care nearer the time that patients are given a terminal diagnosis. The report says that there are multiple opportunities in a patient’s healthcare journey to start honest conversations about future goals and treatments – whether at outpatient appointments, hospital admissions, in social care settings or in the community – as these early conversations allow patients choice and control over the remainder of their lives.
The evidence shows that patients who have had these conversations and have end-of-life care plans put in place have a better experience than those for whom the conversations come in the final days or hours of life when they can seem unexpected to patients and carers.
RCP president Professor Andrew Goddard said,
"This report is a big step forward in helping patients, relatives and doctors to talk honestly about death and dying. We must minimise the barriers in our systems and culture that prevent this from happening.
This is not just about palliative care in the final days, but about having a series of conversations much earlier after a terminal diagnosis."
Professor Dame Jane Dacre, Professor Goddard's predecessor as RCP president, said,
"Patients value and benefit from clear conversations about the end of life. These conversations are difficult, but we need to get better at having difficult conversations."