When I saw my first patient die, I was in shock.  You will never forget your first one, that always stays with you.

My first patient died during medical school, a young guy around 40. He died of complications from endocarditis. He was fine in the afternoon, talking about his family and what he does, but when I came back in the morning he was gone. I was shocked beyond words. Unfortunately with time and age, you get used to it. We adapt and move on, but end of life issues are difficult to deal with, even for the most experienced doctors.

I wrote about the role of hospice earlier. This process starts when a physician starts talking about end of life issues.

During my training at the University of Massachusetts, we were taught to always inquire about the code status at the completion of history and physical. This included either a full code, DNR (do not resuscitate) or CMO (comfort measures only) . However , most of the time this discussion is delayed until it is too late in the game.

Some of the pitfalls I see are:

1. Physicians are weary about inquiring the code status. There may be a certain level of apprehension as they think that the patient may lose confidence in them if they ask this question.
2. Patients may get angry as we all know that we will never die.
3. Often I hear physicians asking patients, “Do you want us to do everything?” In this scenario, the physician assumes that the patient does not want to die.  Information is not carried to the patient properly and the patient makes a vague statement “yes.” But the question is, yes to what? However, code status is entered in the medical record as full code.

I am not an expert in this issue. Usually, this is how I ask them after I am finished with history and physical: “I would like to ask what I ask all my patients — what are your wishes in case your condition deteriorates? I don’t want to do anything which is against your beliefs or wishes.”

You need to ask the patient how they feel or understand about their condition, otherwise it becomes a one sided discussion without giving the patient an opportunity to discuss their perspective.

If they decide to be DNR, then I go over various options which a person can choose from refusal to blood transfusions to refusal of basic CPR or intubation.

It is important to give patient time after each statement for two reasons: i) it gives time for the information to sink in; and, ii) it gives physician time to read patient reaction and space to to maneuver words to soften the impact.

Physicians need to be more proactive about this process.

S. Irfan Ali is a hospitalist who blogs at Human Factor in Medicine and Life.

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