An Internal Medicine Residents’ Perspective on End-of-life Discussions

Sir,

It is known that only around 20% of adults complete advance directives, and the majority do not discuss goals of care or have end-of-life discussions until they are hospitalized with a serious illness. The discussions of advanced directives should not start in the hospital setting; instead, primary care physicians should start these decisions in the outpatient setting. However, there are several barriers to this idealist approach, including, but not limited to history, religion, socialization, and reimbursement issues.[1]

The ability and willingness to discuss goals of care and end-of-life decisions by physicians with families is an important yet undertaught area of medicine. A study from South East Asia showed that internal medicine residents are usually more comfortable and have the most confidence in discussing end-of-life care.[2] While the global applicability remains questionable, this is likely due to the fact that internal medicine residents treat patients with chronic disease more often, which usually require multiple family meetings and discussions over time.[2]

In the community teaching hospital setting, predominantly in the intensive care unit due to aforementioned reasons, internal medicine residents are often the ones that lead the end-of-life discussions and goals of care with support from palliative care and chaplain services. A problem often encountered in this setting is that the patients are unable to make the decisions for themselves, which means that it ultimately falls to the next of kin. Patients typically never have end-of-life discussions with their family before a significant medical event, so it is difficult to know what the patient would want. This is why, it is important to educate patients and their families on the value of having these discussions at a time when the patient is healthy and for physicians to help patients complete advanced directives.

Sadly, the majority of medical students do not participate in goals of care discussions, which is probably why the majority of physicians do not feel comfortable holding goals of care discussions in the outpatient setting.

Most physicians are encouraged to discuss advanced care planning in patients who are terminally ill or have a life expectancy of < 1 year.[3] At the same time, it is of paramount importance to get palliative care involved earlier in the hospital course to help facilitate family discussions which could potentially reduce length and cost of hospital stay significantly.[4] In addition, medical students should undergo additional training with feedback from palliative care physicians not only on the importance of advanced directives but also on initiating and facilitating end-of-life decision-making with the hope that one day, the majority of patients that enter the hospital will have an advanced directive already completed and easily accessible.