During residency training, I often found myself taking care of patients experiencing loss, serious illness, and end of life. I was in the oncology clinic with a patient who came in to see their oncologist for the last time. She was frail because the disease had progressed despite chemotherapy and experimental trials. I was trying to gather the necessary information before the attending came in, when she asked me, “How long do you think I have to left to live?” I wasn’t sure how to answer because no one had ever taught me how.
The oncologist entered and breezed past the patient’s reports of fatigue, nausea, neuropathy, and abdominal pain. Instead, the oncologist explained that conventional treatment options had been exhausted, and the only remaining option was to try another clinical trial. The patient’s eyes widened, as some required invasive procedures, lab values that were already unattainable, or moving away from home entirely.
A silence washed over the room. There was a palpable presence lurking, looming over all of us—an elephant in the room. Death. When would it come? An ideal moment arose to acknowledge it, and I waited for the oncologist to state the obvious to the patient: that she was dying, and would soon die from the cancer, and that it may be time to start making arrangements. But the silence passed, and nothing was said. The patient was given information on clinical trials and like that, the appointment was over.
This was the experience my mother had at her last appointment with her oncologist. Despite having debilitating symptoms and a progressive cancer unresponsive to therapy, the difficult discussion to acknowledge the terminal nature of her disease was never even broached. A few days after the appointment, my mother decided to transition to hospice, and she died 2 months later. Though I accompanied my mother to her last appointment as her daughter, as a resident physician, I couldn’t help but think of the all the other patients and families I had observed throughout my training experiencing similar interactions with their providers.
This scenario highlights an essential part of our practice as physicians: patients deserve honest, compassionate, and effective communication from their doctors so that they can be empowered to make well-informed treatment decisions for themselves and their families. Yet few of us are trained in how to do this well. Whether it be end of life, serious illness, grief, or loss, we as doctors should be able to acknowledge the situation—not only to name it, but to deeply enhance our patients’ understanding of it.
Difficult discussions in obstetrics and gynecology
As obstetricians and gynecologists, we face clinical scenarios that require difficult conversations: a fetal anomaly diagnosed at a routine anatomy scan, a fetal demise discovered in labor and delivery triage, a reproductive abnormality preventing conception found during an infertility workup, or a new diagnosis of cancer on endometrial biopsy. It is our responsibility to meet these challenges alongside our patients, even if it feels hard or uncomfortable.
A key to successfully navigating these challenging situations with patients is to be familiar with an approach to initiating difficult discussions. Once the conversation is started, conducting the discussion with honesty, compassion, and effective communication is fundamental. Looking to oncologic care as an example, we know that conducting end-of-life discussions and early palliative care involvement can lead to improved quality of life, reduced rates of depression, and increased satisfaction with goal-concordant care for patients and caregivers.1-3 It also lowers rates of aggressive medical care near death as well as health care costs and resource utilization.4-7 Benefits such as these can be translated to other patients we care for in obstetrics and gynecology if we are able to utilize similarly timely and effective techniques for serious illness discussions.
Few of us have had formalized education and training in conducting difficult discussions. In a series of survey studies, only 18% of medical students indicated having received formalized training in end-of-life care and up to 53% felt unprepared to address end-of-life issues at the time of graduation.8-9 Recalling their first experience giving bad news, residents reported faculty supervision only 5% of the time, and 88% of residents reported little to no in-class instruction on end-of-life care.10-11 This article will help explain basic principles of communication and provide available resources we can use to improve the process of initiating and conducting difficult discussions.
Thinking about the discussion: common themes
Breaking down the discussion into digestible pieces may make broaching the topic less intimidating. Whether in a clinical scenario involving serious illness, loss, or end of life, there are common themes encountered that we can preemptively prepare for. Figure 1 shows the themes that arise in difficult discussions.
Prognosis
Whether a patient is wondering if pregnancy is possible after treatment of a ruptured ectopic pregnancy or their likelihood of giving birth to a healthy baby after previable rupture of membranes, providers should be prepared to discuss prognosis. Though it may be easier to keep prognosis vague, addressing it clearly and directly is crucial in helping patients make informed health decisions. Discussing prognosis requires the synthesis of clinical knowledge and interpersonal skills such as eliciting patient expectations and understanding, identifying emotions, and responding empathetically. Most studies show that patients want to discuss prognosis and receive detailed information, but it can be daunting for providers to know how to relay that information sensitively and accurately. A good place to start is by simply asking your patient what they already know and what they want to know—asking can facilitate an explicit discussion that matches an individual’s values and needs.12-13
Values
Medical decision-making is influenced by patient values. Personal ethics, sociocultural background, and religious or spiritual beliefs may all have implications in how a patient interacts with health care. For example, a patient with cancer may be unwilling to transition to hospice due to cultural principles regarding death and dying, or a patient with infertility may oppose assisted reproductive technology due to a religious belief. Values also dictate what is most important to patients, such as spending time with family, advancing a career, or being active in the garden. Identifying and understanding your patient’s values is essential to being able to provide a medical recommendation that aligns with their goals and prioritizes what is most important to them.
Relationships
Experiencing serious illness, loss, or end of life may affect your patient’s relationships with family, friends, partners, or coworkers. Whether or not a patient opts for a certain treatment option is often intimately linked with how that choice will affect those around them. Understanding your patient’s social web is imperative to enhancing shared decision-making and providing comprehensive care.
Emotions
Though frequently avoided, minimized, or suppressed, emotions undoubtedly play a role in the experience of serious illness, loss, and end of life for both patient and provider. Accepting and acknowledging the presence of emotion with empathy and support can develop trust, encourage honesty, and reveal what matters most to patients.
Symptoms
Symptoms can be a source of great stress for patients, whether it be related to a fear of developing them or difficulty coping with or controlling them. Anticipating what types of symptoms may arise and knowing how to manage them is a skill that can empower patients and improve quality of life. Proper management could also include appropriate referrals to other specialists such as physical therapy, palliative care, or social work.
Goals of Care
At the conclusion of a difficult discussion, the hope is that prognosis, values, relationships, emotions, and symptoms have all been touched on so that the patient’s individualized goals of care can be determined. Goals of care could revolve around certain desires, the acceptability of specific treatments or intensity of care, or advance care planning such as durable power of attorney, living will, or resuscitative preferences. Whether it be a patient with cancer deciding between “full code” and “do not resuscitate” status, a couple with infertility choosing between known or unknown sperm donor, or a mother with a second trimester loss weighing the pros and cons of evacuation versus induction, defining a patient’s goals of care is universally vital.
Conducting the discussion: implementation strategies
Armed with the knowledge of what themes will likely arise in a difficult discussion, let’s now explore techniques for setting up and conducting the conversation. Figure 2 shows the different components of conducting difficult discussions.
Candidacy
You may ask yourself, which patients are appropriate candidates to have difficult discussions or address goals of care with? Goals of care discussions are relevant to more areas than just end of life—they should be a part of every clinical encounter that involves a decision. Disease-based triggers can also be used to identify patients. Some examples of disease-based identification include diagnoses such as a fetal anomaly incompatible with life, previable rupture of membranes, intrauterine fetal demise, hereditary breast and ovarian cancer syndrome, or platinum-resistant ovarian cancer.
Setting
Timing and place matters. If possible, choose a time of day that is convenient for the patient and a place that is comfortable for them. For example, initiating difficult discussions should be avoided when awakening patients on rounds before the sun rises or calling late in the day when there may not be support people available to them. If it is in clinic, consider a space like a consultation room, away from treatment-related disruptions, or a video visit where they can be in the comfort of their own home.
Participants
Who would the patient want with them when hearing difficult news or making big decisions? Figure out which family members or friends the patient feels supported by most and ask if it is OK to invite them to the conversation. Loved ones can often assist in processing information and creating a psychologically safe space.
Mindset
Consider where both you and your patient are coming from. It is likely you are in two very different mindsets, and the closer you can come to understanding your patient’s way of thinking, the better. Take a moment to walk in your patient’s shoes to appreciate their situation. This includes considering their background and clinical scenario, as well as eliciting their current understanding of their condition. Check in with yourself to cultivate focus and calm. Try your best to eliminate other work distractions and be present when having the discussion.
Therapeutic relationship
Consider the context of the clinical relationship: is this a longitudinal relationship or are you just meeting this patient for the first time as a consult? Your language and approach should be tailored accordingly. Acknowledging and respecting any potential limitations to the relationship contributes to credibility and may help build a bridge more swiftly. Additionally, it is important to partner with any specialists who may be involved in the patient’s care to achieve a unified message.
Takeaways
- Honesty, compassion, and effective communication are the key components to having a successful difficult discussion.
- Obstetricians and gynecologists should be prepared to conduct difficult discussions so that patients are empowered to make well-informed treatment decisions.
- Themes encountered in difficult discussions include prognosis, values, relationships, emotions, symptoms, and goals of care.
- Strategies to implement difficult discussions include determining candidacy; optimizing mindset, setting, and participants involved; respecting the nature of the therapeutic relationship; systematically documenting; and using a stepwise approach.
- Properly addressing these communication issues have the potential to improve patient quality of life, reduce rates of depression, and increase satisfaction with goal-concordant care.
Stepwise approach
Information delivery during a difficult discussion should be approached in a stepwise fashion. First, don’t expect the discussion to necessarily occur all in one sitting. Rather, it is more likely that the discussion will need to occur in increments—possibly over multiple meetings—so that the patient and their family have time to process the information and make decisions. Second, using a “talking map” or conversation guide with patient-tested language to facilitate the discussion can be helpful. Some user-friendly and easily accessible frameworks include the Serious Illness Conversation Guide from Ariadne Labs and quick guides from the training organization VitalTalk. VitalTalk quick guides include tools on breaking bad news, discussing prognosis, responding to emotion, defusing conflicts, addressing goals of care, and more. VitalTalk also offers evidence-based skills training courses, as well as a smartphone tips app, which can be easily referenced just prior to having a difficult discussion no matter where you are.
Documentation
We document clinical encounters in certain ways to streamline our processes in many areas of our practice, and documentation for difficult discussions should be no different. Though each scenario is unique, systematically documenting or using documentation templates help us prepare, practice, and ensure we hit on the absolute essentials. Documenting difficult discussions also shares the patient’s values and goals with other providers, which further supports goal-concordant care.
Conclusion
Conducting difficult discussions is part of what we do as obstetricians and gynecologists. Use the principles outlined in this article to help you implement difficult discussions with honesty, compassion, and effective communication and to empower patients to make well-informed treatment decisions. These general principles of thoughtful communication are simple to adhere to and can make a world of difference in your patient’s life. Use simple, everyday language. Share what you know and admit what you don’t know. Be transparent and vulnerable. Ask clarifying and open-ended questions. Listen. Allow for pauses and silence to create space. Respond to emotions when they come. Be direct yet considerate. Be truthful but sustain spirit.
References
- Hughes MT, Smith TJ. The growth of palliative care in the United States. Annu Rev Public Health. 2014;35:459-475. doi:10.1146/annurev-publhealth-032013-182406
- Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742. doi:10.1056/NEJMoa1000678
- El-Jawahri A, Greer JA, Temel JS. Does palliative care improve outcomes for patients with incurable illness? A review of the evidence. J Support Oncol. 2011;9(3):87-94. doi:10.1016/j.suponc.2011.03.003
- Wright AA, Zhang B, Ray A, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA. 2008;300(14):1665-1673. doi:10.1001/jama.300.14.1665
- Morrison RS, Dietrich J, Ladwig S, et al. Palliative care consultation teams cut hospital costs for Medicaid beneficiaries. Health Aff (Millwood). 2011;30(3):454-463. doi:10.1377/hlthaff.2010.0929
- Schneiter MK, Karlekar MB, Crispens MA, Prescott LS, Brown AJ. The earlier the better: the role of palliative care consultation on aggressive end of life care, hospice utilization, and advance care planning documentation among gynecologic oncology patients. Support Care Cancer. 2019;27(5):1927-1934. doi:10.1007/s00520-018-4457-x
- Sutherland R. Dying well-informed: the need for better clinical education surrounding facilitating end-of-life conversations. Yale J Biol Med. 2019;92(4):757-764.
- Sullivan AM, Lakoma MD, Block SD. The status of medical education in end-of-life care: a national report. J Gen Intern Med. 2003;18(9):685-695. doi:10.1046/j.1525-1497.2003.21215.x
- Fraser HC, Kutner JS, Pfeifer MP. Senior medical students’ perceptions of the adequacy of education on end-of-life issues. J Palliat Med. 2001;4(3):337-343. doi:10.1089/109662101753123959
- Orlander JD, Fincke BG, Hermanns D, Johnson GA. Medical residents’ first clearly remembered experiences of giving bad news. J Gen Intern Med. 2002;17(11):825-831. doi:10.1046/j.1525-1497.2002.10915.x
- Schmit JM, Meyer LE, Duff JM, Dai Y, Zou F, Close JL. Perspectives on death and dying: a study of resident comfort with end-of-life care. BMC Med Educ. 2016;16(1):297. doi:10.1186/s12909-016-0819-6
- Back AL, Arnold RM. Discussing prognosis: “how much do you want to know?” Talking to patients who are prepared for explicit information. J Clin Oncol. 2006;24(25):4209-4213. doi:10.1200/JCO.2006.06.007
- Discussing prognosis: Using the ADAPT tool to guide you through complex conversations. VitalTalk. 2019. Accessed July 7, 2023. https://www.vitaltalk.org/guides/discussing-prognosis/
