• Euphemism free communication

    Paula Span in The New Old Age blog in the New York times has an interesting question-and-answer with Dr. Stephen Workman, an internist from Halifax, Nova Scotia, discussing communication with dying patients, based on some of his recent work. The essence of his communication recommendations are captured is this flow chart:

    Go and read the entire interview. This quote summed up Dr. Workman’s approach to deal with his own patients:

    Q. You specifically say someone is dying?

    A. If death is such a terrible thing that I, the doctor, am unable to face it, then I’m asking too much. If I can’t talk openly about dying, how can my patients and their families bridge that gap?


    S.R. Workman. Never say die?–as treatments fail doctors’ words must not. The International Journal of Clinical Practice 2011;65,2,117-19.

    update: modified language for clarity.

    • Advice like this can obscure how incredibly difficult these situations are. The title is “euphemism free” but under “don’t ask” has “do you want CPR” and “instead ask” “what do you hope for treatments,” which to my reading is more euphemistic, fairly incoherent, and often aggravating. (This wording has a right answer – total cure with no side effects. Next question. : ) )

      As a internist who struggles with these conversations, I wish we had better training and more people giving it serious thought, like Dr. Workman. But the assumption that patients are waiting for the hammer is not what I’ve seen. Many, many patients are not ready for euphemism-free talk initially. It often comes off as rude (eg, walking into a room at 7 am and saying “you’re dying” without at least softening with “doing badly” first) and too-tough-talk will often destroy patient’s trust before you can convince them of the bad news that you think is true and they don’t want to think about.

    • I know communication with dying patients is not easy, not ever, but it still irritates me that doctors always blame the patients and families for their own unwillingness or ineptitude in dealing with the end of life.

      Of course, everyone wants total cure with no side effects, but in a situation where information and experience is so asymmetrical, why can’t we expect more from MDs? Man up, J. You’re getting paid for it…oh, that’s right, you’re not getting paid because that would be a “death panel.”

    • I use the “dying” word a lot. I have had nurses write me up for it at least three times, but not recently. It is not always well received, but I am not there to make friends. I will have to say Dr. Workman has thought it out much better than I have, but I suspect that on a first visit, even he softens it a bit.


    • I agree it is important to pay attention and listen, I FIFE everyone,
      how do you feel,
      what do you think is wrong,
      what can’t you do, and
      what do you hope medicine can do for you?

      Have you thought about the possibility you could die from this illness.
      Yes? What have you been thinking?
      No? Unfortunately the illness has progressed to the point where it is impossible to say how long you could live….

      Brutal honesty is brutal, not honest. But often end of life care is not integrated until death is brought up as a foreseeable but by no means immediate outcome. Uncertainty is the best way to ‘soften’ the blow. The problem is that in the absence of some open discussion immortality becomes the default goal.