Teaching Doctors and Patients to Talk About Death

Communication is often a big issue in cancer care.

Well it’s sad to say, a big issue in cancer is good communication — or bad communication, I should say. Particularly when the discussion entails end-of-life issues.

Both the doctors and the patients are responsible for this because being a doctor or someone with late stage cancer is not going to change a personal ability to communicate. Their goal from the day they begin medical school is to keep patients alive — so patients dying is the worst failure they can face. Talking about it with patients who have come to believe in them is also next to impossible. These are the people who believe in them as something akin to God. How can they let them down.

A study just published in the Journal of the American Medical Association Oncology says that communication training for oncologists and coaching for patients regarding what questions to ask their physicians appears to be effective in improving patient-centered communication for those with advanced cancer. It also results in recognition that it’s only one small option in a field that needs some good, realistic answers.

In the Values and Options in Cancer Care (VOICE) study, physicians took part in an in-office training course. This entailed meeting with an actor portraying the role of a patient and then having a mock office visit. After the visit, the actor would give the physician feedback on his or her communication.

In addition, the researchers trained coaches to help patients identify the most important questions to ask their oncologists during an upcoming office visit.

Patients may not ask questions for a number of reasons, including an assumption that the doctor is telling them everything they know and they see asking questions as challenging the authority of the doctor. I would add a big “you bet” to this one. When we are diagnosed, there is often that assumption that we have a contract with our doctors that if we are “good patients” then they will keep us alive.

Bad patients are the ones that talk back, ask questions, want a second opinion. So, to do any of that is risking your life even more. In addition, patients tend to be more optimistic about their prognosis than their oncologists.

But what role does hope play in a doctor’s reluctance to talk about dying? Oncologists may say they don’t tell their patients about a bad prognosis because they don’t want to remove hope. This is a get-out-of-jail free card that allows them to not discuss end-of-life issues until someone is at the end of life and it’s too late for the letters, videos, goodbyes and all the other things that need to be done when someone is dying.

So how can a doctor proceed with end-of-life issues when no one will talk about death? It is something we have to change.