Discussions about end-of-life issues are difficult for clinicians to
initiate. Patients, their families, and clinicians frequently collude to avoid
mentioning death or dying, even when the patient's suffering is severe and
prognosis is poor. In addition to determining from observational research
when and where communication problems exist, much can be learned from in-depth
discussions with patients, family members, and physicians who are facing these
issues together. Using segments of interviews with a patient with advanced
pulmonary fibrosis, his son, and his primary care physician, this article
illustrates and explores some of these communication issues, including the
who, what, when, why, and how of end-of-life discussions. Studies from the
medical literature, the patient's and physician's particular experience together,
and the author's clinical experience provide practical insights into how to
address these issues. Initiating end-of-life discussions earlier and more
systematically could allow patients to make more informed choices, achieve
better palliation of symptoms, and have more opportunity to work on issues
of life closure.
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