Comprehensive end-of-life (EOL) care is an essential component of oncology. While we aim to cure as many patients as possible, many of them ultimately die of their disease. Our role as clinicians includes guiding patients and their families through the EOL. Comprehensive EOL care encompasses pain and symptom management, psychosocial and spiritual support, caregiver/family support, and discussions about goals of care and advance care planning. This requires skills in communication and symptom management, as well as knowledge of the services available in the community. A multidisciplinary approach is often helpful in providing comprehensive EOL care, and the team may include physicians, nurses, social workers, chaplains, palliative care, and/or hospice.
END-OF-LIFE CARE COMMUNICATION
APPROACH TO DIFFICULT CONVERSATIONS
Patients and families consider communication to be one of the most important aspects of EOL care (1). Discussions about goals of care, treatment preferences, and advance care planning can be difficult for clinicians, as well as for patients and families. In order to lead patients and families through these discussions, clinicians should be proficient in communicating about EOL care. Similar to other components of medical care, these communication skills can be learned and practiced (2).
A clinician can approach a difficult conversation using a series of communication steps that may be remembered by using the mnemonic SPIKES (Table 22-1) (3, 4). The first step in EOL care communication is to prepare for the discussion by asking the patient who he/she would like present in the discussion and by arranging a quiet, private setting with sitting room for all participants (Setup). The clinician should be well prepared for the meeting and know the basic information about the patient's disease, prognosis, and treatment options. The conversation should begin with the clinician establishing what the patient and family know about the illness (Perception) and what specific information they would like to know (Invitation). The clinician can then build on the patient's illness understanding by clarifying realistic goals and addressing unrealistic expectations (Knowledge). In discussions regarding EOL care, patients and families may express a range of emotions, and it is important to allow them to express these feelings and to recognize and respond to them (Empathize). Finally, it is helpful for the clinician to summarize what was discussed, assess the patient and family's understanding, and make a clear plan about the next steps (Summarize and Strategize). These steps can be used in various difficult conversations, including communicating bad news, discussing advanced care planning, and shifting from disease-directed therapy to palliative care (4,5,6).
TABLE 22-1APPROACH TO DIFFICULT CONVERSATIONS