Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

4 tips to remember when end of life discussions go wrong

Monica Williams-Murphy, MD
Physician
May 9, 2013
Share
Tweet
Share

I write a lot about end of life conversations that go well or have unexpectedly positive outcomes. But to be fair and balanced, you should also hear about the ones that don’t go so well, lest you be led to believe that I have magical powers over my patients and their families.

Here are two of my attempted end of life map conversations that did not go over so well. In fact, these conversations left me speechless.

I once took care of a beautiful elderly lady with snow white hair and due to her severe anemia, her skin had nearly the same hue. Looking back over her old records, I recognized a tell-tale pattern for the end of life. She had increasing numbers of recent hospitalizations and was functionally declining fairly rapidly, becoming weaker and weaker. The previous month she could walk with a walker but for the last few weeks she had become bedbound. I steadied myself for an end-of-life mapping conversation to follow my explanation of the blood transfusion we were arranging that day.  I remember saying words like, “I want to give you a very honest picture of what is going on … this pattern often means that she is nearing the end of life …”

Before I could start my next phrase, an adult son interrupted me, “Doctor, my mother isn’t going to die. You don’t understand, we are praying that the rapture comes first so that, she will not die and we will all remain together. We have faith that this will happen. Plus, we don’t necessarily believe that her health ‘pattern’ means she is dying.”

My second encounter was also an elderly female, and this diminutive lady with advanced dementia was also surrounded by a loving and doting family. As I discussed code status for the purposes of this hospitalization for my patient, her son also spoke up, but he said,  “Who wants to die on a machine? Not Mother!”

“Great!” I thought, these people get it.  So, I busied myself writing the family’s stated wishes, which did include full medical treatment but no CPR, shocks or breathing machines should their mother’s body fail. In our hospital we call this a limited resuscitation order with DNR.

I had originally asked if there was anyone else in the family whom I needed to talk to and the initial answer was no. But shortly after, an out-of-state daughter called identifying herself as the power of attorney and said, “I want you to take the DNR order off, because this means you won’t do anything to help her.”

I politely attempted to explain otherwise: “No, I actually had filled out a limited resuscitation order which directs doctors to do everything but place her on machines. And above all, we will help her to be as comfortable as she can be no matter what kind of treatment she is receiving.”

Her response: “Well, I’m a nurse and I don’t believe you.”

Alright now, let’s all take a deep breath and switch gears to think about what happened in each of these cases. Both of these scenarios ultimately involve distrust or disbelief of me, the healthcare provider. Either my assessment of the situation was disbelieved or my stated plan for the patient was disbelieved.

Now, I didn’t have any magic tricks at the time to overcome their disbelief, but in retrospect, I should have worked harder to gain their trust. Since those two encounters, I have thought long and hard about what I could have done differently or what another more enlightened healthcare provider might have done instead.

I have come up with 4 recommendations for myself or anyone else in a similar dilemma:

  • Trust first. We healthcare providers should first trust the idea that the family members may in fact have the best notions about how to care for the patient. This is hard to do. Frequently I walk into the room thinking that I already know what is best for the patient. We just might gain trust by dropping these preconceived notions and instead, becoming open and non-judgmental toward those involved.  I should try harder to understand where they are coming from before I try to communicate where I am coming from. So, I have learned that I should listen and trust first.
  • Be vulnerable. Tell your own story about how you struggled to make the best decision for someone that you have loved- take off the healthcare provider hat for a moment and just be human. This breeds empathy, they will then empathize with you.
  • Demonstrate your moral ethic.  I know that you are ultimately devoted to what is best for the patient. Verbalized this.  It’s powerful to say, “I want to do my best to do what is best for your loved one,” or, “It is morally important for me to tell you the truth about your medical situation.”
  • Be very honest. Sometimes the bald-faced truth must be stated, but it can be delivered compassionately. “I know this is so hard to hear, and I want to talk to you as though you are my brother … (insert truth here).”

So remember, the next time your end of life conversations go wrong, you are not alone. Although I do not have any magic tricks for you, I do hope you will consider trying one or all of these recommendations. After all, when end of life conversations are going wrong, what do you have to lose?

ADVERTISEMENT

Monica Williams-Murphy is an emergency physician and author of It’s OK to Die.

Prev

The path for physicians who want to remain in private practice

May 9, 2013 Kevin 10
…
Next

7 downsides to participating in academic health care social media

May 9, 2013 Kevin 3
…

Tagged as: Palliative Care

Post navigation

< Previous Post
The path for physicians who want to remain in private practice
Next Post >
7 downsides to participating in academic health care social media

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

More by Monica Williams-Murphy, MD

  • Please address suffering in the care of the dying

    Monica Williams-Murphy, MD
  • 8 unexpected reasons why you should have an advance care plan

    Monica Williams-Murphy, MD
  • I may be the only advocate for my dying patient

    Monica Williams-Murphy, MD

Related Posts

  • A real-life example of irrational health care spending

    Taylor J. Christensen, MD
  • End-of-life care talks begin at home: even for doctors

    Abdel Albakri
  • Can the dwindling numbers of primary care physicians explain decreased life expectancy?

    Niran S. Al-Agba, MD
  • Ethical humanism: life after #medbikini and an approach to reimagining professionalism

    Jay Wong
  • A message from a patient to health care workers: Always remember your humanity

    Michele Luckenbaugh
  • Writing tips for physicians from a health care editor

    Debra A. Shute

More in Physician

  • Medicalizing burnout misses the real problem

    Jessie Mahoney, MD
  • Why some doctors age gracefully—and others grow bitter

    Patrick Hudson, MD
  • The hidden incentives driving frivolous malpractice lawsuits

    Howard Smith, MD
  • Mastering medical presentations: Elevating your impact

    Harvey Castro, MD, MBA
  • Marketing as a clinician isn’t about selling. It’s about trust.

    Kara Pepper, MD
  • How doctors took back control from hospital executives

    Gene Uzawa Dorio, MD
  • Most Popular

  • Past Week

    • Why Medicaid cuts should alarm every doctor

      Ilan Shapiro, MD | Policy
    • When the diagnosis is personal: What my mother’s Alzheimer’s taught me about healing

      Pearl Jones, MD | Conditions
    • 2 hours to decide my future: How the SOAP residency match traps future doctors

      Nicolette V. S. Sewall, MD, MPH | Education
    • Key strategies for smooth EHR transitions in health care

      Sandra Johnson | Tech
    • Reassessing the impact of CDC’s opioid guidelines on chronic pain care [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • “Think twice, heal once”: Why medical decision-making needs a second opinion from your slower brain (and AI)

      Harvey Castro, MD, MBA | Tech
    • Why we fear being forgotten more than death itself

      Patrick Hudson, MD | Physician
    • Bureaucracy over care: How the U.S. health care system lost its way

      Kayvan Haddadan, MD | Physician
  • Recent Posts

    • How robotics are reshaping the future of vascular procedures

      David Fischel | Conditions
    • Medicalizing burnout misses the real problem

      Jessie Mahoney, MD | Physician
    • How the shingles vaccine could help prevent dementia

      Marc Arginteanu, MD | Conditions
    • How to survive a broken health care system without losing yourself [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why some doctors age gracefully—and others grow bitter

      Patrick Hudson, MD | Physician
    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Why Medicaid cuts should alarm every doctor

      Ilan Shapiro, MD | Policy
    • When the diagnosis is personal: What my mother’s Alzheimer’s taught me about healing

      Pearl Jones, MD | Conditions
    • 2 hours to decide my future: How the SOAP residency match traps future doctors

      Nicolette V. S. Sewall, MD, MPH | Education
    • Key strategies for smooth EHR transitions in health care

      Sandra Johnson | Tech
    • Reassessing the impact of CDC’s opioid guidelines on chronic pain care [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • “Think twice, heal once”: Why medical decision-making needs a second opinion from your slower brain (and AI)

      Harvey Castro, MD, MBA | Tech
    • Why we fear being forgotten more than death itself

      Patrick Hudson, MD | Physician
    • Bureaucracy over care: How the U.S. health care system lost its way

      Kayvan Haddadan, MD | Physician
  • Recent Posts

    • How robotics are reshaping the future of vascular procedures

      David Fischel | Conditions
    • Medicalizing burnout misses the real problem

      Jessie Mahoney, MD | Physician
    • How the shingles vaccine could help prevent dementia

      Marc Arginteanu, MD | Conditions
    • How to survive a broken health care system without losing yourself [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why some doctors age gracefully—and others grow bitter

      Patrick Hudson, MD | Physician
    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...