End-of-Life Care Should Be Preceded By Candid Conversations

End of Life Care

The best time for candid conversations about an elderly loved one’s wishes about health care, especially end-of-life care, is before a crisis occurs. Guidelines to a drafting living will may help make sure you know what your loved one wants, but other, more subtle conversations must occur also in order to understand the deepest needs, fears, wants, and hopes of your loved one in regard to his or her care These talks may be ongoing during a person’s end-of-life care.

A living will is a directive to medical personnel about what the person wants in end-of-life care if the person becomes unable to express wishes concerning treatment A living will is often called an “advance directive.” It is wise to check your state’s requirements on this. Some states require specific forms that must be filled out as well as other conditions. A living will is not as complicated or expensive as a regular will, though.

While these kinds of legal directives are important, understanding the loved one on a deeper level is equally important. Just because power of attorney is activated for a relative by a living will, it doesn’t mean that end-of-life issues and decisions become clear or easy without prior crucial conversations.

The best time for crucial conversations about an elderly loved one’s wishes about health care, especially end-of-life care, is before a crisis occurs.

 Elisabeth Kübler-Ross suggested in her book On Death and Dying, that we can only learn what a person truly wants through talking, and especially by listening. Surgeon Atul Gawande recommends this in his book Being Mortal. He emphasizes crucial conversations between doctors and patients, but most often illustrates conversations between family members and patients in which the patients expressed what they really wanted. Then the path became clear and made the medical procedural questions easier to answer.

In an end-of-life situation, Gawande and Kübler-Ross agree, it is important to learn the person’s understanding of his or her situation. Kübler-Ross says it is not whether a patient should be told of, say, a terminal diagnosis, but how the knowledge should be shared with the patient. The patient’s stages of denial, anger, bargaining, depression, and acceptance should never be rebuked or dismissed. Gawande and Kübler-Ross agree that it is important not to close the door on hope, but hope should be tempered with realism.

Gawande quotes Susan Block, a palliative care expert, on the questions that arise in these crucial conversations. The first is one Kübler-Ross, Gawande, and Dr. Block all endorse and which was mentioned previously: What is the person’s understanding of his or her health situation? The next question is: What are the person’s fears and concerns about it? It is important to ask: What are the goals if the condition worsens? Finally, it is significant that the person know: What trade-offs are worth making? What is the person willing to risk for what possible outcomes? What things are non-negotiable?

Gawande and Susan Block participate in The Conversation Project, which seeks to get people talking about their end-of-life care: what they value, what they fear, what they hope for, and what they are willing to accept or not accept.

Although these conversations are very difficult to conduct, they are crucial. Often they clear the air and facilitate decision-making. Although they are easier to avoid when a person is doing well, it is not too soon to start such conversations, even hypothetically, in order to know the senior on these important points.

Dr. Block suggests that the first step is to start to think about having such a conversation or planning your own journey into what you want for the end of life. We will all face it. Knowing what we think and what our loved ones think about these issues contributes to everyone’s peace of mind.




The Conversation Project website (n.d.). Available online at: http://theconversationproject.org/about/susan-block-md/.

Gawande, A. (2014). Being Mortal. New York: Metropolitan Books. Henry Holt and Company. Pp. 211-212.

Kübler-Ross, E. (2014). On Death and Dying, reprint edition. New York: Scribne