Tips for communicating with the patient who wants to 'do everything'

One of the more difficult situations I encounter, particularly on the inpatient unit, is the patient who wants to "do everything." Sometimes, in the face of incurable metastatic cancer, this means more chemotherapy, sometimes it means total parenteral nutrition, sometimes it means living on a ventilator in the ICU. And to most of us, although we agree with patient autonomy and the ability of the patient to decide what treatments they do and do not want, we still feel as though we are "flogging" our patients in this situation.

I was relieved to come across an article addressing communication skills in this difficult scenario this week in the Annals of Internal Medicine by Quill, Arnold and Back. I particularly like Table 2, which includes suggested responses to patients' comments to elucidate the potential meaning of "doing everything" (for example, if the patient says, "Don't give up on me," the suggested response is, "What worries you the most?"). I also very much appreciate the section on harm reduction if the patient does decide on burdensome treatments. It is these burdensome treatments that most clinicians are hoping to avoid. However, rather than repeatedly bringing up the issue with the patient in the hopes that they may change their mind, the authors suggest that a short but genuine effort at these treatments indeed be attempted (one round of CPR, rather than the "slow code"), which seems to me to honor the desires of all involved. A very useful review article for all oncologists and hematologists.