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Lessons for the End of Life

Andrew G. Shuman, MD, and Susan D. McCammon, MD, said it is essential to be clear of what the patient’s goals are at the end of life.

End of life conversations are not easy for anyone. However, it is essential for otolaryngologist-head and neck surgeons to understand their patients’ wishes as there are any number of terminal diseases in otolaryngology, including nasopharyngeal cancer, invasive fungal sinusitis, brainstem lesions, and temporal bone squamous cell carcinoma.

According to Susan D. McCammon, MD, from the University of Alabama, Birmingham, when a patient asks her, “Am I going to die?” she tries to ascertain if the question is based on emotion or gaining knowledge.

“If it is a knowledge question, we can provide the data and the stats. We are good at that,” she said. “But if it is an emotion question, we should acknowledge and ask what the patient is most frightened of. In asking the question, you learn more about the thinking of the patient, and it helps give them a feeling of control.”

Andrew G. Shuman, MD, from the University of Michigan Health System, cautioned the audience to make certain the patient is hearing the right words and distinguishing between, say, incurable and terminal.

“We do not want to bludgeon people with the information.” he said. “Frame it in a straightforward and blunt manner but frame it around the patient’s goals.”

Dr. McCammon agreed. She said that is why she doesn’t like the word disfigurement when dealing with head and neck cancers. “I prefer to tell the patient that it will change the way he or she looks. I do not want them to perseverate on the length of the incision,” she said.

There is also a stigma associated with palliative care and hospice, said Dr. McCammon. Patients often confuse the two.

The panel advised these four steps:

  • Ask questions of your patient. “What frightens you most?” “What do you value in life?” Understand their religious and spiritual attitudes. Your patients should feel comfortable discussing their beliefs and possibly of miracles without the fear of  being dismissed. It gives the doctor the opportunity to work with them, “If a miracle doesn’t happen, what can I do?”
  • Find out what the patient’s goals are. This allows you to frame it for the patient as you progress through treatment. “You said your goals were this. This will or will not help you achieve these.”
  • Discuss DNR status with terminal patients.
  • Consider early palliative care consultation for patients with metastatic disease.

In the end, assure your patient “We are going to do everything to help you and nothing that will hurt you,” said Dr. Shuman.