I call it ‘the grim reaper talk’. By this slightly tongue in cheek phrase I refer to the vital timely episode of communication I have with a patient’s family when we as the multidisciplinary team feel someone has entered the final stages of their life in terms of hours or days. I will sit down with the relatives somewhere quiet away from the patient’s bedside and after exploring the baseline understanding of the current clinical situation and explaining all the treatments we have tried without success, will gently then introduce the idea that we feel their loved one is dying and that perhaps our interventions are actually causing unnecessary suffering without having a beneficial effect. Often I find people completely agree with our observations and sometimes there is an audible sigh of relief in the room. Eyes well up and tears usually start to flow, but I find that the most frequent verbalised response is “she wouldn’t have wanted all this.”
In an ideal world I will have already built some form of relationship with my patient’s relatives and have explained the care journey on a couple of occasions before we actually get to ‘the grim reaper talk’ but unfortunately the way that the modern NHS works with lack of continuity, more often than not this will be the first time I have ever had a conversation with these people. Showing that you truly care and promoting the comfort and dignity of that individual patient is of paramount importance. I try not to erase all hope during these difficult conversations and always try to communicate the uncertainties we face in these situations. The future is impossible to predict and no-one has an accurately functioning crystal ball. Occasionally patients improve and rally when active treatment is discontinued and everyone working in specialties involving palliative care will have witnessed this.
I do not want to forget the patient in all this. Perhaps we spend proportionately more of our time speaking to relatives in Elderly Medicine due to confusion or other communication barriers but it is absolutely imperative that the patient remains central to all decision making and where possible they should always take an active role. The pragmatism and stoicism that older people exhibit has always been and remains an inspiration to me on a daily basis and has helped me come to terms with my own personal situation immensely.
As part of my non-clinical work I am part of the End of Life Strategy group at my hospital. One piece of work I have been involved with recently for this group is an analysis of complaints made about end of life care to see what we can learn from when things do go wrong. The vast majority, if not all complaints made in this setting are centred on communication failures. Perhaps a ‘grim reaper talk’ has not occurred and because of this a death has come seemingly out of the blue even though a patient has been noticeably deteriorating whilst in hospital from an already frail baseline. As senior doctors working in specialties such as Elderly Medicine I believe we all have a duty to help to train our junior doctors not only in the skills and knowledge necessary to work safely in acute medicine but also in the communication skills necessary to hold these conversations effectively; much of this comes from observation and supervision, which is a challenge in itself in the time-deprived and staff poor NHS environment.
The problem is that achieving excellent communication with both patients and their relatives in this setting takes a great deal of time, effort, experience and skill. The pressurised working environment that we all face every day on NHS wards is not really conducive to achieving this. However, we must remember there is only one opportunity to get communication right at the end of life and people will remember those conversations we have with them forever more. I believe the quality of this communication also has some impact on how easy the grieving process will be. We as doctors and nurses need to remember this and try our hardest to show as much empathy as we possibly can always thinking about how we would feel if it was our loved one that was facing the very final stages of their life.