End of Life Techniques to Support Difficult Conversations Professor Mayur Lakhani Derived from and adapted for use from the work of Professor Stephen Workman (Canada) with acknowledgements  

When to Initiate a Discussion about Death and Dying At diagnosis of life limiting or progressive condition Clinical deterioration: pain or distress Patient indicates desire to know prognosis In answer to direct question from doctor: “Would you like to talk about your prognosis, what you can expect and what is likely to happen in the future?” Prompt from family Repeated unplanned admission Ask yourself the question “would I be surprised if this person died within the next 6-12 months?”. If no, then consider advance care planning

Talking about Dying When a patients condition deteriorates do not just say “your mother is seriously ill” add: “she is at risk of dying” or “it is possible that mother will die” “Your father is very ill. Even with the very best treatment it is possible he may not survive” “I am sorry. I wish I could give you some other news, but treatments are not working. We need to consider what to do next” “We have done everything possible to allow your father to survive. All I can do at this point is to allow him to die with as much comfort and dignity as possible and to help you deal with this terrible loss” If death occurs do not say “passed away” or “passed on” or “has gone to sleep”. Do use the word “died”

Talking about CPR Start with “do you know what CPR is?”, “what are you hoping CPR will do for you?”, “have you thought about the kind of treatments you would want if you suddenly became very ill?” “The chances of CPR working are very low and would not allow your loved one to survive. It would be better to keep you comfortable and allow a natural and dignified death” Do not say “do you want CPR”; if there is disagreement, say: “it helps us to understand why you want these treatments, can you tell us your reasons?” Allow a natural death or a naturally dignified death i.e added after “in my opinion, the chances of your mother surviving CPR are very small, it would be much kinder and better to allow a natural death”

Finding out about Prior Thoughts Have you ever talked about these kinds of issues with your father? Do you know what kind of treatment he would want? Do you know if there are any reasons he would want us to stop these treatments? Can you explain to me what you have been told about your husband’s condition?

Further information Workman, S. R. ‘Never say die? – as treatments fail doctors’ words must not’, International Journal of Clinical Practice, Vol. 65, Issue 2, p.117-119 (Dec 2011) Workman, S. ‘Your Mother has passed’, Xtranormal [http://www.xtranormal.com/watch/11063145/your-mother-has- passed] (07 Feb 2011) Workman, S. ‘A Shared Decision’, Xtranormal [http://www.xtranormal.com/watch/8266060/a-shared-decision] (14 Jan 2011)  Workman, S. ‘A communication model for encouraging optimal care at the end of life for hospitalized patients’, QJM: An International Journal of Medicine, vol. 100, Issue 12, pp.791-797 (2007)

Further information http://www.bbc.co.uk/news/health-18101418 http://www.dyingmatters.org/gp_page/professor-mayur-lakhani-my-experience Lamas, D, and Rosenbaum, L. ‘Becoming a Physician: Freedom from the Tyranny of Choice — Teaching the End-of-Life Conversation’, The New England Journal of Medicine, vol.366 pp.1655-1657 (May 2012) General Medical Council. Guidance on Treatment and care towards the end of life [http://www.gmc-uk.org/End_of_life.pdf_32486688.pdf] p.10 (May 2010)