Life is full of developmental stages, from prenatal to early childhood, adolescence, and middle and late adulthood. What’s often left out of the equation is death and dying, according to Karen Wyatt, MD, California-based retired family and hospice physician and host of the “End-of-Life University” podcast. And that’s a mistake, she said, resulting in many lost opportunities for doctors to deliver better care when patients reach the end of life.

Around 35% of Americans die in the hospital, which makes it particularly important that hospitalists are equipped to have end-of-life discussions with patients and their families. Yet many doctors come poorly prepared for these moments, leaving them uncomfortable when the conversations are necessary.

“Most doctors receive training in how to deliver bad news surrounding a diagnosis, but that’s about it,” said Wyatt. “Doctors like cures and staving off death.”

Training teaches physicians and nurses to fix things. A broken bone requires a splint, and an infection requires an antibiotic. Grief and dying, or the anticipation of them, are antithetical to what medical practitioners want to do.

The issue is often compounded by the fact that patients and their families haven’t had these conversations, either, said Terri Daniel, inter-spiritual chaplain and grief counselor based in Portland, Oregon, who holds a Doctor of Ministry in Pastoral Care and Counseling from the San Francisco Theological Seminary.

“Part of the problem is that we live in a death-phobic culture,” she said. “The saddest thing I hear from families is that they never talked about death or how a patient might want end-of-life care to go.”

Hospitalists are in a unique position in this regard, with the ability to see the big picture. Other doctors and care skew toward a siloed approach, but hospitalists get a comprehensive look at the illness trajectory. For this reason, you can step into difficult conversations and ensure that patients and families receive compassionate care and counseling in this final stage of life development.

Preparing for Difficult Conversations

No one wants to give a patient bad news, and having difficult conversations around the end of life often leaves doctors wringing their hands. But with some reframing, physicians can get more comfortable with end-of-life conversations, said Kristina Newport, MD, chief medical officer at the American Academy of Hospice and Palliative Medicine.

“It’s a relatively new concept that our only job is to keep people alive longer,” said Newport. “The root of medical care is to relieve suffering and help people live as well as they can.”

Modern medicine — with its tools and medications — has offered physicians many treatment options for extending life. But often, that life extension comes with a lower quality of life. Taking a hospice approach, however, affords patients the opportunity to improve quality of life, even if it doesn’t prolong it.

This mindset shift can be helpful to hospitalists facing patients with a poor prognosis. “If you can couch it as helping people live better because you’re open and honest with them about what they can expect with their diagnosis, use that as a starting point,” said Newport.

Rethinking your “north star” with care to help patients have a better end-of-life experience is essential, said Newport. Aiming to help patients maintain dignity and personhood can be a goal, along with understanding what’s important to them in their final months, weeks, or days.

Setting that goal is one thing, but achieving it is another, and this is where the right conversations and approaches come into play. Before you speak, however, you must consider a patient’s family culture.

“An American Jewish family will respond differently than a Japanese family,” said Daniel, “and while you can’t make generalizations, having some understanding of cultural pockets helps.”

In addition to understanding cultural nuances, you should also know if the patient’s family has a point person for contact, if not the patient themselves. “Make sure they are aware of the truth,” said Daniel. “Tell them, ‘Here’s what the outcome will be, regardless of the treatment options.’”

Withholding the truth of the diagnosis is never okay, she said.

Keeping the family in the mix is an emerging area of study that reveals patients have better care when their loved ones are involved. “That’s not how we’re trained,” said Newport, “but it’s the standard in palliative care.”

To help with these difficult conversations, experts suggest you bring in a palliative care team sooner rather than later. “They are trained in these conversations and focus on comfort,” said Wyatt. “This allows you to focus on treatment, but conferring with the palliative team will help you deliver quality of life.”

What to Say

Once you’ve embraced the idea of holding end-of-life conversations, it’s important to include all the right elements to help your patient. Most doctors believe they talk honestly about the trajectory of an illness, but they worry about taking away hope, according to Wyatt.

“You can maintain hope by delivering the best quality of life,” she said. “Regardless of how much time is left, your patient can have high quality, comfort, and enjoyment. Emphasize to your patient that you’re on the same team.”

Ensure your patients and caregivers understand their illness and prognosis. “Dementia, for instance, is a terminal illness,” said Wyatt. “If the patient and their caregiver don’t understand this and the typical progression, they might be surprised and request treatments that aren’t beneficial.”

Discuss with your patient what life might look like in a year if they choose to continue treatment. “If they are 83 and have multiple illnesses, no matter what, the line goes downward,” said Daniel. “So, the decision is palliative care or treating and prolonging that downward trend.”

It’s important to describe what palliative care would look like. It’s an end to aggressive treatment and no surgery, but it’s also symptom management. “Anything that happens outside the terminal illness, we’ll treat,” said Daniel, “but not the progression of the illness.”

When a patient asks for specific timelines on his or her illness, you may not have the answer, and that’s ok. Aim for a general timeframe, but emphasize that statistics don’t apply to everyone. Instead, tell your patient that the focus should be on making their time as positive as possible.

At the end of the day, primary palliative care is a skill set all doctors should have, according to Newport. “An interdisciplinary approach is important, but don’t downplay how big a role hospitalists can play,” she said.

When a hospitalist can step up to the plate and ask the patient if it’s okay to bring in the hospice team, it’s a rare gift, said Daniel. “My fantasy is that doctors bring in a social worker and a palliative care team to have a discussion,” she said. “It’s a different kind of care, one that is based on comfort and preparation for end of life.”