title: Beyond advance directives: importance of communication skills at the end of life.
abstract: Patients and their families struggle with myriad choices concerning medical treatments that frequently precede death. Advance directives have been proposed as a tool to facilitate end-of-life decision making, yet frequently fail to achieve this goal. In the context of the case of a man with metastatic cancer for whom an advance directive was unable to prevent a traumatic death, I review the challenges in creating and implementing advance directives, discuss factors that can affect clear decision making; including trust, uncertainty, emotion, hope, and the presence of multiple medical providers; and offer practical suggestions for physicians. Advance care planning remains a useful tool for approaching conversations with patients about the end of life. However, such planning should occur within a framework that emphasizes responding to patient and family emotions and focuses more on goals for care and less on specific treatments.
authors: The Center for Palliative Care and the Department of Medicine, Veterans Affairs Medical Center and Duke University, Durham, NC, USA. jtulsky@duke.edu
authors: James A
authors: JA
authors: Tulsky
mesh_terms: D016223:Advance Directives; D003110:Colonic Neoplasms / Q000556:secondary / Q000628:therapy; D003142:Communication; D003657:Decision Making; D006801:Humans; D007400:Interprofessional Relations; D008113:Liver Neoplasms / Q000556:secondary / Q000628:therapy; D008297:Male; D008875:Middle Aged; D010166:Palliative Care; D010190:Pancreatic Neoplasms / Q000473:pathology / Q000628:therapy; D010817:Physician-Patient Relations; D013727:Terminal Care