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For many clinicians, broaching the topic of serious illness is challenging. It’s not easy to share the news of a poor prognosis and to witness the pain of the patients and families on the receiving end. Having a conversation near the end of life can feel like an acknowledgement that the care provided has failed. 

Some physicians may conclude that they have nothing left to offer if there is nothing more they can do medically. In today’s busy healthcare environment, many clinicians feel they lack the time. Add in the fact that physicians receive little to no training in medical school about how to have these conversations in a meaningful way, it’s no wonder they struggle with initiating them.  

The following are guidelines on how you can initiate advance care planning conversations with your patients. 

Identify the Right Time

A change in a patient’s medical condition may indicate the time is right to bring up the topic of end-of-life care. You can identify the need for a conversation by asking yourself if you would be surprised if the patient dies in the next year.  Whenever a patient is admitted to the hospital, diagnosed with a serious illness, or during a follow-up, ask this question to determine if a discussion should ensue.

Ideally, the first serious illness discussion is not the last, as patients’ preferences may change as severity of illness worsens and how outcomes of therapy are described. Each conversation should lay the groundwork for the next. 

Prepare Ahead of Time

Conversations about end-of-life care are among the most essential services clinicians can provide. As such, they deserve forethought and planning. Here are some tips to help you prepare:

• Make time– Schedule enough time to have a thorough discussion. Being rushed minimizes the critical nature of the conversation.
• Make space– Choose a private, quiet area where everyone can be seated.
• Eliminate disruptions– Turn off your cell phone and pager and remove anything from the room that could cause distraction or interruption.  
• Avoid putting it off– It’s much easier to have the conversation earlier in the disease process before a crisis occurs. 
• Envision the conversation– Take a few minutes beforehand to visualize how the discussion may evolve.
• Get assistance– Enlist the aid of a palliative care clinician, hospice nurse or social worker, if appropriate.  
• Use training resources– build your skills and comfort level with training that will help guide you through the discussion, such as with ACP Decisions’ Advance Care Planning modules for clinicians.

Ask Open Ended Questions

Advance care planning involves finding out what patients’ goals are regarding medical care and quality of life during serious illness or in the event they are unable to speak for themselves. It is also important to discover what cultural and religious values play a role in these goals. Additionally, when it comes to talking about serious illness or the end of life, it is necessary to find out what the patient and family understand about the diagnosis, so that any clarifications can be made. 

In each case, it is most effective to have an open discussion that involves equal amounts of listening and talking. The best way to facilitate such a conversation is to ask open-ended, probing questions and listen closely to the responses. Here are examples of questions you could ask to initiate and guide the conversation:

• “I want to be certain that I have clearly explained your medical situation. Can you give me your understanding about what is ahead for you?”
• “As your clinician, I want to make sure we are always doing the things that might help you, and that we never do anything that either can’t help you, or you wouldn’t want. So, I need to know what things are most important to you, given your illness. How do you want to spend your remaining time?”
• “You said that you don’t want to suffer—what type of suffering are you talking about?”
• “You mentioned that you don’t want to be a burden to your family—what do you mean by that?”
• “Are there any circumstances in which you believe life-prolonging treatment would not be desirable?”
• “A few months ago, we spoke about what kind of care you would want if you were to become very ill. We’re now facing that situation. Can you tell me if your thoughts are the same, or if they have changed in any way?”

By using these tips to initiate serious illness conversations, you will be showing compassion and building trust with your patients. You’ll be able to conduct thoughtful and meaningful advance care planning discussions that evolve comfortably and naturally. Above all, you will be enabling your patients to improve their quality of life on their terms, while giving them the opportunity to die with comfort, peace, and dignity. 

Find further advance care planning resources in our Advance Care Planning Guide Part 2: List of Resources. You can also use our Advance Care Planning Training Modules for Clinicians if you would like to learn how to go through the advance care planning process with your patients, from introducing the concept to translating the conversation into an actionable plan.  

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