Pearls for empathetic critical care at end of life

Key takeaways:

• Critical care requires trust and vulnerability.
• Especially at the end of life, the way a practitioner communicates with both the patient and their families can lead to building trust.

HONOLULU — Critical care, especially at the end of a patient’s life, requires practitioners to not only be vulnerable, but to accept and communicate uncertainty and to build trust with both the patients and their families.

Margaret Pisani, MD, MPH, FCCP, delivered the Roger C. Bone Memorial Lecture at the CHEST Annual Meeting and used her time to reminisce upon cases and mentors throughout her storied career that have helped her to become a better critical care physician.

“[Bone’s] research over the course of his career was focused on understanding shock and sepsis, and how we can best care for critically ill patients by treating their bodies. But what I gleaned from his writing after he became ill was that he came to realize we were not doing our best for our patients if we do not address how to care for them at the end of their lives,” Pisani, professor of internal medicine in pulmonary, critical care and sleep medicine at Yale School of Medicine, said during her lecture. “Being a doctor and caring for critically ill patients allows you the luxury to experience the whole range of human emotion. And how amazing is that? I feel privileged to be able to bear witness.”

The language of dying

Pisani first addressed the need for physicians to reconsider the use of language in dealing with serious illnesses. Being able to convey the importance of what is happening is paramount to building trust with the patient’s family and to being clearly understood. This may require separating clinical assessments from the deliberation about next steps.

The use of the word “dying,” for example, is one way to change the language surrounding serious illness.

“We often use euphemisms to try to convey to families that their loved one is going to die. We need to speak in terms families can understand,” she said. “The words we use and how we say them matters.”

Additionally, adding “what this means” and “what to do next” statements to discussions can help families to better understand the process, Pisani said.

Accepting uncertainty, vulnerability to build trust

Pisani also stressed the need to not only accept the unknown, but to be able to convey that uncertainty with patients and families. It is also important, she said, to be vulnerable to your emotions and the emotions of those around you.

Uncertainty is both natural and unavoidable and vulnerability requires you to share your own personal feelings, mistakes and emotions, she said.

“One of the challenges of caring for patients in the ICU, and especially at the end of their lives, is not only recognizing they are dying, but also being able to live with the uncertainty about our predictions. ... It is hard for us as physicians to live with uncertainty,” Pisani said. “I realized there was a very human component to ICU care that required acceptance of and the ability to convey uncertainty, and also required you, as the physician, to be vulnerable.”

This includes being honest with patients about the uncertainty of life expectancies, which can lead to the most important part of critical care: building trust.

“Whether we want to or not, we all bring our whole selves to care for our patients. We should take time to really listen and work on building trust,” Pisani said. “Trust is not only essential to a patient-doctor relationship, but to the functioning of society.”