With the end in mind

Post by Claire Donohoe (@clairedonohoe6), Editorial Assistant BJS, Consultant Oesophagogastric surgeon, Dublin

We need to talk

A critical role of the surgeon is having difficult conversations with patients and their families. Continuously improving our communication skills is as important an aspect of professional development as staying abreast of technological changes. Recent papers in BJS have highlighted the importance of clear decision making at the end of life regarding when to operate1, 2. Recent global events bring the matter in sharper focus.

One potential barrier to making appropriate decisions is engagement with patients, in a time critical manner, to determine their core values and preferences regarding end of life treatment. In “Learning from Regret” the authors noted that perceived communication barriers, regarding poor prognosis with little prospect of ultimate survival, lead to surgeons undertaking emergency surgery and subsequently regretting this decision when they reviewed their patient’s death retrospectively2. In their leader on a “good surgical death” Chamberlain and Blazeby note the importance of early identification of patient’s goals and warned of the rescue culture and death denial that can results in the surgical arena1. Joliat et al. could only identify seven studies in their systematic review which addressed the impact of patient death on surgeons, none of which included interventions to reduce negative impacts3.

Approaching a difficult conversation

Story telling is a powerful tool for enhancing reflection and a potential way of promoting practice change4. “With the End in Mind” is written by a palliative care specialist Dr Kathryn Mannix. In it, she utilises a series of composite accounts of deaths of patients during her career, to illustrate how the experience of death can be managed, symptoms palliated and people comforted5. This book is available for free download in the UK and Ireland until April 6th through this link.  This book aims to give us permission to directly discuss dying.

From a personal perspective, some of the important themes which led me to reflect on my personal practice included how to address the potential collusion of silence between patients, families and healthcare professionals by ensuring that knowledge is shared and exploring what barriers may exist to a shared understanding of what is happening. This can help promote mutual support within families and facilitate open communication by setting the tone.

By taking the lead on broaching difficult conversations, the healthcare professional can take some of the power of un-named worries away and relieve some of the burden of the taboo. Similarly, by directly addressing the usual trajectory of the decline to death in the metastatic cancer setting as well as the well-recognised in the last days and hours of night as described eloquently by Dr Mannix, I have found a sense of control can be imparted to the dying patient and their supporters.

Infographic prepared by Scottish Quality Safety Fellowship Cohort and Open Change on approaching discussions about dying. Reproduced with authors permission.

How to put it into practice?

Some of the lessons from this book and others have been incorporated into an infographic by cohort 12 of the Scottish Quality Safety Fellowship working with design partner Open Change to illustrate an approach to end of life communication entitled “Difficult Conversations – Why we need to talk about dying”. The focus is on breaking down an approach to end of life conversations using honesty and compassion. It provides a framework for the novice and an opportunity to reflect for the more experienced practitioner.

Mastery can enhance a personal sense of control. Mastering communication skills in fraught situations is fundamental to the provision of high quality surgical care and might perhaps, reduce some of the effects of secondary victimhood experience as we care for our dying patients6.

Acknowledgements

With thanks to Dr Lara Mitchell (@laramitchdr), Consultant Geriatrician and Clinical Lead, and Hazel White, Director Open Change (@openchangeuk) for their insight and providing access to their communication resource.

1.            Chamberlain C, Blazeby JM. A good surgical death. BJS 2019; 106(11):1427-1428.

2.            Boyle FM, Allen J, Rey-Conde T, et al. Learning from regret. BJS 2020; 107(4):422-431.

3.            Joliat GR, Demartines N, Uldry E. Systematic review of the impact of patient death on surgeons. British Journal of Surgery 2019.

4.            Zaharias G. What is narrative-based medicine?: Narrative-based medicine 1. Canadian Family Physician 2018; 64(3):176-180.

5.            Mannix K. With the End in Mind: Dying, Death and Wisdom in an Age of Denial. London: Harper Collins, 2017.

6.            Pellino G, Pellino I. Deaths, errors and second victims in surgery: an underestimated problem. BJS 2020; 107(1):152-152.

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