Beyond Advance Directives
Importance of Communication Skills at the End of Life
- James A. Tulsky, MD
- Author Affiliations: The Center for Palliative Care and the Department of Medicine, Veterans Affairs Medical Center and Duke University, Durham, NC.
- Corresponding Author: James A. Tulsky, MD, Center for Palliative Care, Duke University Medical Center, Hock Plaza, 2424 Erwin Rd, Suite 1105, Durham, NC 27705 (jtulsky{at}duke.edu).
Abstract
Patients and their families struggle with myriad choices concerning medical treatments that frequently precede death. Advance directives have been proposed as a tool to facilitate end-of-life decision making, yet frequently fail to achieve this goal. In the context of the case of a man with metastatic cancer for whom an advance directive was unable to prevent a traumatic death, I review the challenges in creating and implementing advance directives, discuss factors that can affect clear decision making; including trust, uncertainty, emotion, hope, and the presence of multiple medical providers; and offer practical suggestions for physicians. Advance care planning remains a useful tool for approaching conversations with patients about the end of life. However, such planning should occur within a framework that emphasizes responding to patient and family emotions and focuses more on goals for care and less on specific treatments.
