Ushering in the Good Death (the Bona Mors)

We all know how precious end-of-life conversations with our patients can be. These are times holy encounters that should be a major component of our vocation as healthcare professionals. However, in the midst of a busy day, they often take a back seat and sometimes are inappropriately viewed by us as get in the way of our “urgent to do” list. Remember that St. Gianna Molla called this our “priestly mission.”

Recently I had a patient transferred to me in the ICU from another institution who had stage IV lung cancer. As we talked about the plan for his care, he asked, “Doc, how long do I have to live?” Not knowing what he had been told by his previous physicians, and wanting to understand where he was in his thinking, I replied, “I’m sure my answer will not be too different from what you’ve already been told by your other physicians and medical team.” To which he gave me a squirrely look and replied that he had never had that conversation with any of his previous doctors. Of course it’s possible that he actually did and simply didn’t recall it, but it’s also possible that he is like many other patients you and I have seen who didn’t get such issues addressed even though they obviously should have. Anyway, as my patient and I connected on this immensely important topic, his family members were all sitting a few feet away in the window of the ICU room. They listened intently and asked questions themselves.

I want to share three short points about the conversation:

First, while it is exceedingly hard to predict how long someone will live without a crystal ball, it is very important to “flip” this question in a helpful manner. Rather than merely guessing about how long he/she might live, I always make sure that my patients and their families know how quickly they could pass away (telling him something like, “I don’t know how long you will live but considering how sick you are, it would not be surprising if you die in the next days or weeks” – in accordance with the truth of his/her circumstances).  This allows the patient and loved ones to make plans and reconcile relationships in a tighter timeframe.

Second, out of respect for each and every person’s belief system, I always take the opportunity of such a conversation to ask patients about their spiritual values. In fact, in our physical diagnosis course, the way that we teach medical students to take such a history in a nonjudgmental and open manner is as follows: “Mr. Smith, do you have any spiritual values that you want us to know as your medical team that would influence your medical decisions?” We get a variety of extremely helpful responses from atheists, agnostics, Hindus, Buddhists, Jews, Christians, and so on. Such answers allow me to either avoid the topic altogether if the patient prefers or to seek religious professionals if preferred.

Thirdly, on this particular occasion something happened at the very end of the conversation that was quite fun. As I was walking out of the room, the family asked if they could speak to me privately. Of course, I said yes and they followed me outside and began to whisper, “Doctor, we just want you to know how thankful we are that our dad has such a devoted Baptist doctor!” To which I smiled and happily replied, “It’s my privilege to serve him and your family.”

 

Wes Ely, MD, MPH (wes.ely@vanderbilt.edu)

 

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