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6 Questions Every Doctor Should Be Asking Patients

 |  By jfellows@healthleadersmedia.com  
   January 22, 2015

End-of-life care for sick patients is garnering more attention from hospitals and health systems because of its impact on costs. Now leaders need to invest in training physicians to talk to patients about their concerns and wishes.

Angelo Volandes, MD, MPH, is passionate about patients. More specifically, he fervently believes that every physician has a responsibility to give patients information they need to make decisions about the medical interventions they want when they are dying. It's not an easy conversation, and Volandes believes, it's not optional, either.

Hospital and health system leaders are eyeing palliative care programs closely because the ROI is there to support the move toward a more compassionate way of caring for a sick patient. Studies have shown that patients who received palliative care in the hospital in the last week they were alive, had significantly fewer ICU admissions and fewer instances of ventilator use.

In a HealthLeaders Media webcast this week on the strategic use of palliative care, speaker R. Sean Morrison, MD, co-director of the Patty and Jay Baker National Palliative Care Center, as well as director of the National Palliative Care Research Center, and professor of geriatrics and medicine at the Icahn School of Medicine at Mount Sinai, called palliative care "essential" to responding to the aging population.

"Palliative care teams relieve symptoms, distress, and uncertainty; communicate what to expect and match treatment to patient and family goals; and help coordinate care."

6 Questions
As a hospitalist at Massachusetts General Hospital, Volandes sees the need for palliative care in his patients continuously. As an assistant professor of medicine at Harvard Medical School, he shows residents firsthand how to have these difficult conversations. But it is his newest venture, as an author, where Volandes goes straight to the heart of why end of life options are so important for families, and patients.

His recent book, The Conversation, profiles seven critically ill patients, including his father. Through their stories, he drives home the importance of talking to patients about how they want to die. He admits these conversations are hard, but he says physicians need to be asking their patients six questions; and if doctors aren't asking them, patients should take the lead.

  1. What kinds of things are important to you in your life?
  2. If you were not able to do the activities you enjoy, are there any medical treatments that would be too much?
  3. What fears do you have about getting sick or medical care?
  4. Do you have any spiritual, religious, philosophical, or cultural beliefs that guide you when you make medical decisions?
  5. If you had to choose between living longer or having a higher quality of life, which would you pick?
  6. How important is it for you to be at home when you die?

See One, Do one, Teach one
Doctors spend most of their days asking their patients questions, so why is it so difficult for doctors to ask the really hard questions, like the ones above? Volandes says it is because doctors are so focused on solving clinical problems that they forget they are talking to people.

"I teach medical, pre-med students, and residents," says Volandes. "What I try to do is help them understand how critically important it is to have a conversation. They'll see me start the conversation with a family, then I have them go to the next patient and lead the conversation. I have them teach it to one of the younger residents. It's a powerful experience."

Unfortunately, says Volandes, this kind of communication training is not widespread among medical schools. Knowing that doctors weren't getting this kind of training, Volandes says he focused his efforts on empowering patients to speak up and have these conversations with family members and doctors.

To that end, he co-founded Advance Care Planning Decisions, a nonprofit organization aimed at educating patients and their families about the options for end of life care through short, high-quality videos.

Volandes started out developing these videos in his living room with his wife and various family members and friends playing the roles of patient and physician, working through common questions he heard from patients in his practice, and also showing physicians how to ask tough questions (his wife didn't need to act; she is a physician, too). The videos have become such a popular training tool that shooting has moved to a real studio.

In one video, a patient tells Volandes, who is in the real-life role of doctor, that she doesn't want to have a conversation about her end of life care.

"I don't really want to talk about this," she says. "I'm okay now, I'm not sick now."

It raises the question of when to start talking to patients? The answer, Volandes says, is soon and often.

"The best time is when the patient is feeling great, when they have their wits about them, and not critically ill," he says. "This is not a one-time conversation. Doctors should be having these routinely. At a minimum, with anyone over 65, with a critical illness. [Otherwise] it's depriving them of having their wishes honored. We are so compartmentalized that we think we have to pass it off to the oncologist or cardiologist. No, this is a fundamental part of your job."

The focus on empowering patients has turned into a valuable resource for physicians, too. Volandes says 70?100 medical providers are now using the videos to help jumpstart these end of life conversations, including the entire state of Hawaii.

"That's what I didn't expect," he says. "I see physicians, in their documentation, using lines from the video."

The phrase, 'Doing the right thing for our patients,' is uttered more and more around boardrooms and hospital floors. Opening the door to a difficult conversation with patients and their families shows true physician leadership. Doing what is right isn't always easy.

"You're depriving a patient an opportunity to say goodbye, to get their finances in order. I understand these are tough conversations. But trust me; after you have your first, [and] your second, your patients are so appreciative. When we ask patients, they say this is one of the best moments I have had with their doctors."

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Jacqueline Fellows is a contributing writer at HealthLeaders Media.

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