Ensuring competency in end-of-life care - Communication and relational skills

Physician competence in end-of-life care requires skill in communication, d ecision making, and building relationships, yet these skills were not taugh t to the majority of physicians during their training. This article present s a 7-step approach for physicians for structuring communication regarding care at the end of life. Physicians should prepare for discussions by confi rming medical facts and establishing an appropriate environment; establish what the patient (and family) knows by using open-ended questions; determin e how information is to be handled at the beginning of the patient-physicia n relationship; deliver the information in a sensitive but straightforward manner; respond to emotions of the patients, parents, and families; establi sh goals for care and treatment priorities when possible; and establish an overall plan. These 7 steps can be used in situations such as breaking bad news, setting treatment goals, advance care planning, withholding or withdr awing therapy, making decisions in sudden life-threatening illness, resolvi ng conflict around medical futility, responding to a request for physician- assisted suicide, and guiding patients and families through the last hours of living and early stages after death. Effective application as part of co re end-of-life care competencies is likely to improve patients' and familie s' experiences of care. It may also enhance physicians' professional fulfil lment from satisfactory relationships with their patients and patients' fam ilies.