It has been 15 years since I walked across a stage in Dallas, Texas, and became a doctor of medicine. Since that day, I have learned that I don't have all the answers, I make errors, and I am not superhu-man. I have also realized the tremendous grace, trust, and privilege accorded to me by my patients and their families. One of my profession's singular most challenging and profound responsibilities is the necessity to have end-of-life conversations. This is a task that I will never master, yet it is proba-bly the highest calling of my career as a hospice physician.
As medical professionals, we are trained to perform 'Time Outs' before procedures and follow proto-cols and Breslow tapes during trauma activations and Code Blue events. There is no Breslow tape, no Parkland formula, no UpToDate page for how to tell someone that they are dying. We are trained to constantly search for and offer treatment, surgery, and medication to address the condition in front of us. In this approach, we learn to be astute clinicians, but we lose the ability to pause and appreciate the human being struggling with the condition we are attempting to treat.
A defining experience of humanity is death. All of us are born, and all of us die. Eventually, we will all develop a condition or experience a trauma that will culminate in the universal mortal experience of death. Learning to recognize and honor death is not a cultural norm. Doing so has had a significant impact on how I practice the art of medicine. There are some things that I've learned along the way that may be helpful to others, and I hope to share those with you.
You never know when an end-of-life conversation may occur. You may be a family physician seeing a 45-year-old mother of two for an uncomplicated urinary tract infection when she discloses that her 12-year-old son was just diagnosed with stage IV cancer. You might be checking your mail post-call when a neighbor stops by to ask for your help navigating 'what to do' for their elderly parent intu-bated after a massive stroke. It is imperative to recognize when to pause and take a 'time out' for palli-ative care. It is equally important to realize when you have the personal emotional and professional capacity to approach an end-of-life conversation.
One of the first things I do when facing an end-of-life conversation is acknowledge I am a fallible, mortal human being and do not have all the answers, but I will do my best to treat my patient as I would want to be treated. Even if I have to go searching for a chair, I sit down and start with an in-ternal 'time out.' I ask the patient and family present to describe what is occurring in their own words, and I listen. I allow space, even if it is filled with uncomfortable silence. I tell the patient and their family that I have important news about their health, and I ask permission to have an honest and possibly difficult conversation. I encourage questions and make sure there is a family member present, if possible, to help take notes. I try to empower the patient to leave the conversation with a sense of control over their care.
That typically sounds something like, "Mr. Jones, I want to have an honest conversation about your condition. I want to be as honest and upfront as I can be to help you have control over your care.”
All these conversations are unique. None follow an exact sequence of events or protocol. That is OK. It's OK that these are hard conversations, and it's OK that they challenge us. We are human under-neath our white coats. The most important lesson that I have learned in caring for the dying is to care for myself, for I am dying too. I have to recognize the grief and anxiety that this work causes and make sure that I am accountable for my well-being and self-care. Self-care is not selfish. It's critically important for us to decompress and recognize signs of burnout before they become incapacitating.
The work that we do every day as healthcare providers is hugely important. We make tangible differ-ences in the lives of our fellow human beings with our mastery of science and application of the art of medicine. Navigating care at the end of life is a privilege and an honor. It is my calling as a physician, and I hope that my experiences prove helpful to you.
Lauren Loftis MD received her medical degree from UT Southwestern Medical School in Dallas, Texas and is dual board certified in both Family Medicine and Hospice and Palliative Care. She serves as Chief Medical Officer for St Francis Reflections Lifestage Care.
