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
