Ranjana Srivastava, an Australian oncologist, highlights the critical yet often avoided topic of end-of-life conversations between doctors and patients. She shares a personal anecdote about a patient with advanced cancer, illustrating the difficulty and necessity of discussing mortality. Despite the patient's resilience, Srivastava feels a duty to gently shift her thinking toward planning for deterioration, acknowledging that such conversations are rare and challenging.
The Gap in Serious Illness Conversations
According to Srivastava, holistic care for incurably ill patients must include discussions about death and dying, but getting there is hard. A new study underscores this gap: only 10% of patients had documented serious illness conversations in advance care planning sections without any intervention. Nudging clinicians raised this to 16%, and combined nudges to both clinician and patient reached 17%. When scanning entire medical records, conversations occurred in 22% of controls, 28% with clinician nudges, and 32% with both nudges.
These findings reveal that serious illness conversations don't happen as often as warranted, leading to enormous costs for patients and society. When they do occur, they are often poorly documented, leaving emergency professionals without critical information.
Nudging Doctors, Not Just Patients, Is Key
The study tested four groups: patient-only nudge, clinician-only nudge, both nudges, and a control group. Patient nudges alone had no effect on documented conversations. However, clinician nudges significantly increased documentation. Srivastava notes that telling patients to have difficult conversations with their oncologist doesn't work; instead, reminding doctors is more effective, and simultaneous reminders for both parties yield the best results.
Barriers for clinicians include lack of communications training, time constraints, and burnout. Srivastava argues that despite these challenges, change is possible and necessary through insight into the importance of these conversations and foresight in building better healthcare systems.
The Human Impact
In her practice, Srivastava gently initiates these discussions, emphasizing the importance of planning for worsening health to honor patients' families and themselves. She recounts a patient who thanked her for the conversation, highlighting the relief such dialogue can bring. “Thank you, I needed to hear that,” the patient said, underscoring the value of addressing mortality openly.
