Talking with patients about death and issues of dying is difficult, but most patients are interested in discussing end-of-life care with their physician. Balaban provides advice on how physicians can become more at ease in conducting these discussions with patients.

The author describes a four-step approach for discussing end-of-life care (see the accompanying table). Studies have shown that patients want to discuss end-of-life issues with their physician, but they want the physician to introduce the discussion.

The first step is to initiate a discussion. The physician-patient relationship must be supportive, and the physician should show empathy and compassion. The author suggests introducing the subject of end-of-life care by saying something such as “I know this is a very difficult time for you and your family. You have never been this sick before, and I know it must be frightening to you. I want you to know that as bad as it is, we will deal with it together.” In addition to physical decline, the patient may want to talk about emotional and spiritual suffering.

Identifying a surrogate decision maker early in the process is important. The physician may say,“I would like to know how I should care for you if you were to become very ill…. If you ever become so ill that you are unable to speak for yourself, who would you want to make decisions regarding your medical care?” It is also important to explore what the patient means by certain phrases. For example, the physician can explore the patient's perceptions by asking, “You said that you don't want to suffer. What type of suffering are you talking about?” “You said that you don't want to be kept alive as a vegetable. What does that mean to you?”

The second step is to clarify the patient's prognosis. The physician must be direct and unequivocal (when possible). For example, the author recommends a statement such as “This cancer is getting the better of you. The treatments…are no longer working…. Your desire to feel better is not realistic.” Avoiding medical jargon and repeating the information will increase the patient's comprehension. Information should usually be presented on a sixth to eighth grade level. Asking the patient to explain what he or she has just heard may also be helpful.

The third step is to identify the patient's end-of-life goals. This step occurs once the patient and family acknowledge that death is approaching. Previous discussions can be used as a guide for what is asked. What had once been a hypothetic situation is now being faced by the patient and family. At this time, it may be useful to verify that the patient continues to have the same thoughts about the issues that were previously discussed. Understanding the patient's and family's motivations may also be important, especially in cases where the patient or family members say that they want “everything done.”

The final step is to develop a treatment plan that includes determining a site of care, the type of pain control and the use of aggressive treatments. If an explicit discussion of attempted resuscitation has not occurred, it must take place. The patient and family members must be comfortable with do-not-resuscitate orders. If there are doubts, this issue must be discussed. For example, the physician may say, “You look uncertain about this. We don't need to decide at this moment. Let's talk more about this at our next meeting.” It is unusual for a patient or family to request aggressive interventions if it is clear that these interventions will not extend life or will only prolong the dying process.

The author concludes by emphasizing that caring for a dying patient can be gratifying for the physician and, when it is done well, end-of-life care can be comforting for the patient and family. As the author states, “To help someone die in comfort, in peace and with dignity is to give one final gift of life.”