Nursing Book Club
The Conversation: A Revolutionary Plan for End-of-Life Care
How to have the hardest talk
Reviewed By Christine Contillo, RN, BSN, PHN
To help a patient at the end of life have what has come to be known as “a good death,” we as clinicians need to have a serious and often difficult conversation about what exactly that means. The answer is different for everyone. For some, it’s knowing that no treatment was left untried. For others, it’s being able to enjoy the time that’s left. To help a patient at the end of life have what has come to be known as “a good death,” we as clinicians need to have a serious and often difficult conversation about what exactly that means.
The answer is different for everyone. For some, it’s knowing that no treatment was left untried. For others, it’s being able to enjoy the time that’s left. In his 2015 book, The Conversation, author Angelo E. Volandes, M.D., examines how patients, families and providers can approach these questions. Gone are the days of patriarchal care, when the doctor or head of the family unilaterally decided what should be done.
Volandes emphasizes thoughtful, informed conversation. He stresses that as much as possible, it’s the patient who should be making the choice, but it must be made while the patient is still competent. The same is true of the designation of a medical proxy who can speak for the patient if the patient is incapacitated or non compos mentis. Volandes has some useful suggestions about how and when to bring up these topics.
Facing the Options
End-of-life care often boils down to three options: to continue life at any cost (i.e., life-prolonging care); to keep the patient comfortable while no longer aggressively treating a terminal condition (i.e., palliative care); or some middle ground between the two (i.e., limited medical care). Volandes offers a few novel ideas to help patients and families choose which option is right for them.
One is a tour of the ICU to show the family how their loved one would be handled and the amount of technology sometimes necessary to keep a patient alive. Another idea is a video for families to watch about artificial respiration and feeding tubes, allowing the family to ask more educated questions. Of course, technology and procedures aren’t the only considerations. Religious and spiritual beliefs are important, as are questions like what the patient considers meaningful and what they still hope to accomplish in their lifetime.
Volandes describes several specific examples of families facing these situations and explains the decisions they came to. Interestingly, he admits that in several cases, he would have guessed wrong about what the family would have wanted. I found it refreshing that Volandes is a medical doctor willing to admit some things that many physicians will not.
Most importantly, he acknowledges that most physicians are not good communicators and often won’t voluntarily initiate an end-of-life conversation even though the time spent doing so may be covered by Medicare. Sometimes, nurses who spend more time with chronically ill patients may be able to facilitate this type of discussion. I know that I’ve often suggested questions that patients I’ve cared for should ask their doctors.
The author’s most important point is this one: “Small fixes do not change the larger picture … fixing specific problems may not fix the whole patient.” This emphasis on holistic care is the ultimate purpose of this book. Even with all our technology and interventions, there can be precious few options for a patient in decline. Most of us have been in the position at one time or another of realizing a patient doesn’t have much time left, but their family doesn’t understand or hasn’t accepted the reality. This small book can help drive these difficult but critical conversations forward.
This article is from workingnurse.com.