von Gunten CF, Ferris FD, Emanuel LL. Ensuring Competency in End-of-Life CareCommunication and Relational Skills. JAMA. 2000;284(23):3051-3057. doi:10.1001/jama.284.23.3051
Author Affiliations: Center for Palliative Studies, San Diego Hospice, San Diego, Calif (Drs von Gunten and Ferris); the Education for Physicians on End-of-Life Care (EPEC) Project, the Interdisciplinary Program on Professionalism and Human Rights, Northwestern University Medical School, Chicago, Ill (Dr Emanuel).
The Patient-Physician Relationship Section Editor:
Richard M. Glass, MD, Deputy Editor.
Physician competence in end-of-life care requires skill in communication,
decision making, and building relationships, yet these skills were not taught
to the majority of physicians during their training. This article presents
a 7-step approach for physicians for structuring communication regarding care
at the end of life. Physicians should prepare for discussions by confirming
medical facts and establishing an appropriate environment; establish what
the patient (and family) knows by using open-ended questions; determine how
information is to be handled at the beginning of the patient-physician relationship;
deliver the information in a sensitive but straightforward manner; respond
to emotions of the patients, parents, and families; establish goals for care
and treatment priorities when possible; and establish an overall plan. These
7 steps can be used in situations such as breaking bad news, setting treatment
goals, advance care planning, withholding or withdrawing therapy, making decisions
in sudden life-threatening illness, resolving conflict around medical futility,
responding to a request for physician-assisted suicide, and guiding patients
and families through the last hours of living and early stages after death.
Effective application as part of core end-of-life care competencies is likely
to improve patients' and families' experiences of care. It may also enhance
physicians' professional fulfillment from satisfactory relationships with
their patients and patients' families.
Physician competence in end-of-life care requires skill in communication,
decision making, and building relationships. Physician ability in this area
correlates directly with patients feeling satisfied with their medical care
and adhering to medical advice, as well as indirectly with liability litigation.1- 3 It may also substantially
enhance physicians' own experiences of providing care. Yet, these skills were
not taught to the majority of physicians in practice during their training.
We present a 7-step approach for structuring the communication of important
information. It expands on the approaches described by Buckman4
for the communication of "bad" news to include setting treatment goals, advance
care planning, withholding or withdrawing therapy, making decisions in sudden
life-threatening illness, resolving conflict around medical futility, responding
to a request for physician-assisted suicide, and guiding patients and families
through the last hours of living and early stages after death. A review of
the literature supports this overall approach to structuring such conversations.5
The first 3 of the 7 steps prepare the patient, caregivers, and physician
for discussing important information. After delivering the news, the last
3 steps permit the physician to respond to the patient's reactions and establish
a plan. The steps' discrete and sequenced presentation is only a model to
guide practice and the acquisition of proficiency (Table 1). In clinical practice, steps will be accomplished in different
ways and with varying intervals, or even sequence.
Step 1 is preparing for the discussion. To prepare, physicians should
confirm the medical facts of the case, establish an appropriate environment,
make sure that enough time is available to communicate the information effectively,
and ensure that everyone the patient would like to have present is able to
attend. Step 2 is establishing what the patient (and family) knows. Beginning
with open-ended questions establishes what the patient and/or family know
about the patient's situation. Step 3 is determining how information is to
be handled. More than 90% of US residents would rather know the truth about
their illness, especially if it is one that will be fatal.6
However, because people handle information differently, it is important for
physicians to first determine how each patient wants to have information shared.
Patients have the right to decline to receive information. Physicians should
not assume that an individual's preferences track with ethnic, cultural, or
To minimize the risk of communication errors, step 3 might best be accomplished
at the beginning of the patient-physician relationship before specific news
needs to be given. Sometimes family members ask the physician not to tell
the patient the diagnosis or other important information. While it is the
physician's legal obligation to obtain informed consent from the patient or
proxy, an effective therapeutic relationship is enhanced by a congenial alliance
with the family. Such requests should prompt an open-ended question to find
out why the family doesn't want the patient to be told. After the physician
has listened attentively to the family, a suggestion to go to the patient
together may result in a discussion that leads to a mutually satisfactory
plan for information sharing.
Similarly, when the patient is a child, the parents may want to protect
the child from distressing information. Yet, most children will perceive that
there is a serious health problem and may develop distrust if information
is withheld. It may be better to communicate important medical information
to the child at an age-appropriate level. A similar family discussion may
allow for such an approach to occur harmoniously.
Step 4 is delivering the information in a sensitive but straightforward
manner. Language should be clear and neither overstate nor understate the
implications of the news, or the precision of knowledge conveyed by the information,
whether diagnostic or prognostic. Frequent pauses are important to check for
understanding and to allow time for everyone to absorb the information.
Step 5 is responding to emotions. Patients, parents, and families will
have a wide range of emotional reactions to important news. They will need
time to react, and the physician should listen quietly and attentively. Many
reactions are short-lived. Once the emotion is expressed, people tend to move
on more easily. Attention to this step conveys respect and support, and strengthens
the patient-physician relationship.
Step 6 is establishing goals for care and treatment priorities. This
step is discussed in greater detail in the next section. It may be less relevant
when delivering new or serious information. If goals cannot be discussed after
delivering news, this step can be addressed at a subsequent meeting.
Step 7 is establishing a plan. Additional information should be gathered
and further tests that may be appropriate should be discussed. The overall
care plan, including treatment of current symptoms and sources of ongoing
emotional and practical support, should be developed. This 7-step approach
to communication can provide guidance in several types of encounters in end-of-life
care. Before examining each in turn, we will further examine step 6.
Numerous legitimate goals for medical treatment exist, including cure
of disease, prolongation of life, avoidance of premature death, maintenance
or improvement in function, relief of suffering, improvement of quality of
life, preservation of control, achievement of a good death, and support for
families and loved ones. Although goals may seem to stretch along a continuum
in a linear fashion, multiple goals may apply simultaneously, and some may
seem to be contradictory. Sound clinical decisions routinely require prioritization
among potentially contradictory goals.
After establishing the patient's current medical situation, and before
settling on specific medical treatments (ie, before step 7), additional open-ended
questions should be asked. Questions to ask may include, "What's important
to you now?" or "What are you hoping for?" These help to establish the patient's
and family's view of the future. With an understanding of patient's and family's
needs and expectations, the clinician can better propose realistic goals and
how they can be achieved. It is often appropriate to identify those things
that cannot be done, either because they will not help achieve the identified
goals or because they are not possible.
There is a historical medical convention that clinicians should express
hope for full recovery, even if it is not a realistic hope.7
The principle has been taken so far as to administer treatments that are known
to be ineffective, all in the service of maintaining hope. However, perpetuating
false hope may prevent the patient and family from finding meaning and value
in the time remaining to them. At a time when people most need emotional closeness,
collusion to persist in unrealistic goals may prevent reconciliation, emotional
growth, final gift giving, and closure. Some physicians find it useful to
frame discussions using phrases like, "We can hope for the best, but we also
need to plan for the worst."
In discussing goals of care, inept phrasing, even if well-intentioned,
may have unintended consequences. For example, a comment of "It's time we
talk about pulling back" can imply abandonment. To prevent unintended consequences,
it is useful to develop facility with language that reinforces the goals of
appropriate medical care. An example would be "I want to give the best care
possible until the day you die."
Advance care planning is a form of settling on goals for care. It is
intended to guide future medical care in the event that the patient is unable
to make his/her own decisions. Most patients believe that it is the physician's
responsibility to start advance care planning and will wait for the physician's
Once introduced, the patient, proxy, and family can do most of the work on
their own. Another member of the health care team (eg, a nurse, social worker,
chaplain) can also help.
An advance care planning discussion should begin by asking how familiar
the patient is with the concept, and whether he/she is prepared to engage
in the discussion. Some patients may already have advance directives in the
form of a living will or health care proxy. Others have had experiences with
family members or friends who were too ill to make decisions for themselves.
After eliciting their understanding and willingness to discuss the subject,
the clinician should explain the goals and the process he/she recommends.
Even if the patient is able to make decisions, the patient's decision maker
should be included in the discussions from the outset. Advance care planning
often focuses only on resuscitation decisions. It is more useful to engage
in a structured approach that includes the types of clinical scenarios that
might arise, and the decisions that patients and proxies most commonly face.
Validated worksheets covering a range of clinical scenarios may facilitate
face-to-face discussions between the physician and the patient.11- 13
They also may be used to capture the key points made by the patient. Once
the discussion is complete, these worksheets may be used to summarize the
conversation so that the patient's final choices can be entered directly into
the medical record.
While many physicians believe that advance care planning is time consuming
and inadequately reimbursed, the time that the physician takes to counsel
and provide information about advance care planning may be incorporated into
the coding of the complexity of each patient encounter.14
Any statement of a patient's wishes, written or oral, that can be considered
a valid statement should be binding, but a formal written document signed
by the patient helps to avoid ambiguity. Patients should be encouraged to
complete 1 or more documents (eg, a living will or durable power-of-attorney
for health care) that comply with the relevant state statutes where the physician
practices. Physicians can inquire about these documents at their hospital,
state attorney general's office, or local medical society.
Finally, the patient's advance directives need to be available when
decisions are being made. Copies of the documents should be distributed to
all relevant parties. The patient may want to carry a wallet card or wear
a medical bracelet that specifies the whereabouts of these documents.15
Goals of care can change and it may become necessary to discuss withholding
or withdrawing 1 or more therapies.16 Often
these discussions involve the proxy or family and can draw on the trust and
common understanding of prior communication and planning. Two examples that
illustrate such discussions follow.
Food and water are widely held symbols of caring. Suggestions that artificial
nutrition and hydration be withheld may be misperceived by the patient, family,
or other caregivers (professional and volunteer) as neglect if the context
for the discussion is unclear. To establish the context, the medical condition
of the patient should be discussed and overall goals of care reaffirmed. Next,
the physician should address whether artificial hydration and nutrition will
achieve those goals.
In many cases, artificial nutrition and hydration will neither reverse
the underlying pathology nor make the patient feel better. For example, if
the goals are improved energy, weight, and strength in a patient with far-advanced
cancer, artificial fluid and nutrition are unlikely to be helpful.17- 19 In fact, such interventions
may make edema, ascites, pulmonary secretions, and dyspnea worse, particularly
if there is significant hypoalbuminemia. While many believe that the patient
must be hydrated until death, a state of relative dehydration in a patient
who is bed-bound and imminently dying may have some benefits. Pulmonary secretions,
vomiting, and urinary incontinence may be diminished, and dehydration may
actually stimulate the production of endorphins and other endogenous anesthetic
compounds that contribute to the patient's sense of a peaceful, comfortable
The clinician should listen for misperceptions when asking the patient
and/or family what they understand about the current situation. They may believe
that lack of appetite and diminished oral intake of fluids are causing the
patient's level of disability. They may assume that if the patient could get
more fluids and nutrition, the patient would be stronger. Clear, simple language
should help them understand the real causes of the situation. The family may
also need help to recognize their emotional need to care. Then, with the help
of other professionals, the family can find other ways to express their need.
Getting a DNR order should never be the sole motive for a discussion
with a patient or family. Rather, a DNR order best emerges naturally from
a discussion of the approaches and interventions that will be taken to achieve
their overall goals for care. Engaging in isolated discussions about cardiopulmonary
resuscitation (CPR) and DNR status may leave the patient or proxy confused
and anxious about the future, and may be perceived as pending abandonment.23
Most patients (and some physicians) are unaware that CPR was developed
for and remains most appropriate for unexpected events, such as an intraoperative
event or cardiac arrest in an otherwise healthy patient.22
It was not developed and is not indicated for the reversal of the final stages
of an otherwise irreversible disease.24,25
Once the patient's goals for care have been reviewed, whether CPR would be
likely to achieve those goals should be considered. The answer is usually
During the discussion of CPR, clinicians should avoid 2 unfortunate
linguistic conventions. First, language such as "starting or shocking the
heart" or "putting on a breathing machine" can imply a false sense of reversibility
and independence of organ function. These phrases suggest that heart and lung
functions are isolated problems. In the setting of advanced illness, circulation
and breathing usually stop because of the relentless progression of the disease.
Second, the convention of describing CPR as "doing everything" has the implication
that not doing CPR is "doing nothing." Clinicians should not suggest abandonment
when there is much that can be done for all patients until death.
The discussion should be completed with a proactive care plan (step
7) for the patient. For some patients, full medical intervention is appropriate
to achieve their goals for care, even with a DNR order in place.
Situations of sudden life-threatening illness usually involve prognostic
uncertainty and the need for rapid and frequent decisions. Multiple physicians
and numerous other members of the health care team may be working simultaneously
to save the patient's life. Managing symptoms and preparing the patient and/or
family for the possibility of death or incomplete recovery may be given a
lower priority than is desirable.26- 28
In addition to the basic approaches for interacting with patients discussed
previously, the following points deserve emphasis in these rapidly changing
situations in which tensions are often high.
Regular times should be scheduled for 1 person from the family and 1
from the health care team to meet to discuss the patient's situation. Regular
communication is likely to reduce confusion and avoid misunderstandings. In
these situations, emotions tend to be prominent, fragile, and sometimes so
powerful that rational understanding is difficult.
During these conversations, overall goals of care should be discussed
and confirmed frequently, particularly as new information becomes available
or the patient's condition changes. The range of possible outcomes should
be communicated fully to help the patient (or parents if the patient is a
child) and family make informed choices. The clinician should try to be realistic
about the possible degrees of recovery and identify decision points in the
future when additional information will be available that will help with decision
making. Symptom management should be addressed in the initial plan of care.
Even if the prognosis is uncertain and information is limited, it is
counterproductive to wait to communicate until substantive new information
is available. Frequent updates of even incremental information give the patient
and family time to prepare.
An initial plan that includes symptom management will allow the care
intended to comfort the patient to continue even when life-sustaining treatments
are discontinued. This will minimize the risk that the family will feel that
the patient is being abandoned as therapies are withdrawn.
Resolving conflicts over medical treatment requires particular skill
in communication. When applying the 7-step approach to communication, elucidating
the patient's and family's understanding of the situation (step 2) is critically
In probing for that understanding, insight into the causes of conflict can
help to facilitate resolution.
Conflicts about futility are usually the result of misunderstandings,
lack of attention to the family's (or physician's) emotional reaction to the
patient's dying, or a conflict in values, rather than a disagreement about
the medical facts.
Misunderstandings and/or emotional reactions such as distrust, grief,
and guilt can manifest themselves as a conflict over futility. Descriptions
of how other physicians were wrong, the previous hospital was not good, the
patient's previous physician was only interested in money, the nurses never
answered the call lights or administered the wrong treatments, racial or ethnic
prejudice was suspected, etc, should trigger the question of trust. It is
often helpful to address this gently but directly. Emphasizing what is being
done for the patient and offering to facilitate a second opinion or find other
individuals whom the patient and family are more likely to trust may help
to restore trust. An explicit statement that everyone wants the best care
for the patient and reinforcing the goal of working together to achieve the
best possible care also may help. The clinician can affirm that accurate and
complete information will be shared based on mutual trust and respect.
Conflict over issues of futility may be an extension of anticipatory
grief. Social work, chaplaincy, nursing, and other disciplines can help the
physician offer support. In making decisions, the family needs help distinguishing
between what the patient would want and what the family wants in response
to their grief.
Two powerful motivators for human behavior are guilt and unfinished
personal business. The archetypal, not-so-subtle situation for either of these
is the arrival of the long-estranged or distanced relative at the bedside
saying, "You must do everything; you can't let her die." Elucidating these
tensions requires skillful interviewing and the willingness to assess the
situation using a broad perspective. Because guilt is sometimes associated
with a sense of shame, and unfinished business is often painfully private,
families may not readily reveal these issues to the physician. Active listening
and involvement of multiple team members over time are usually essential.
Conflicted relationships are rarely resolved and the resultant guilt is rarely
eliminated. However, understanding that this conflict exists may illuminate
behavior that previously seemed inexplicable. With time and carefully planned
discussion, a resolution may be achievable.
Family dynamics that manifest themselves as conflicts over futility
may not be initially apparent to the physician, particularly if the physician
does not see the entire family as a group. A family meeting at which the physician
is present and in which all parties get together to hear information and make
decisions can be an excellent way to both acknowledge intrafamily issues and
come to a decision with which everyone can agree.
Many people have a firm religious foundation for their lives and the
decisions they make. This may extend to decisions about medical treatments
and life-sustaining therapies. The physician should explore how religious
issues influence the patient and his/her family in decision making. Physicians
may need to overcome the social convention of avoiding religious topics to
have this discussion. Relying on chaplains, or perhaps the family's own spiritual
leader, to help discuss and elucidate the patient's or family's religious
framework can be helpful. The physician can clarify what is in the physician's
power to influence, and what is not. Miracles are, by definition, rare. Such
conversations need to be scrupulously attentive to accuracy and appropriateness.
Sometimes the relative value of life is a source of conflict. To resolve
this tension in a practical way, it may be helpful for the physician to focus
on the patient's point of view, including his/her goals for care and wishes
expressed previously in advance directives, either formally or informally.
Many physicians are likely to receive a request for hastened death at
some point in their careers.36- 45
It is quite common for patients with a life-threatening illness to think about
suicide, if only in passing. Some will approach the physician with the intent
of "thinking out loud."
All requests should prompt the physician to assess the reasons for the
request using a broad conceptual framework for suffering that includes all
of the issues related to the physical, psychological, social, spiritual, and
practical dimensions of life.
To elicit specific information about the type of request that is being
made and the underlying causes for it, the physician should ask open-ended
questions in a nonjudgmental manner.40 While
some fear that talking about suicide or hastened death will increase the likelihood
that the patient will act, this fear has not been substantiated.42
Particular consideration should be given to the possibility of clinical depression
or anxiety; these conditions are associated with requests for hastened death.38 When evaluating psychological and social issues,
the patient's fears about his/her future should be explored. Many patients
have witnessed suboptimal care in others that fuels their fears of losing
control, being abandoned, being a burden, or being undignified.42
The physician should make a commitment to help find solutions to those
concerns, both current and anticipated, reinforcing that he/she wants to continue
to be the patient's physician until the end. Options to allay immediate concerns
and fears should be explored.
Patients may not be aware of the legal alternatives available to them.
Patients should understand that they have the right to consent to or decline
any treatment or setting of care if any of them seem too burdensome, including
the voluntary cessation of fluid and nutrition, either enterally or parenterally.22
For the rare patient who has unbearable and unmanageable pain, or other
intractable symptoms after maximal palliative care, and is approaching the
last hours or days of his/her life, the induction and maintenance of a state
of sedation may be an option.42 Sedation in
the imminently dying that is intended and managed to produce a level of obtundation
sufficient to relieve suffering without hastening death has a firm ethical
basis.39 This can be achieved safely using
appropriate medications (eg, benzodiazepines, barbiturates, or anesthetic
agents) and accepted dosing guidelines.46 Medications
that are poor sedatives (eg, opioids) are not appropriate for this purpose.
If a patient with intractable symptoms is sedated, it is the intended effect
that is important. If the patient dies while receiving sedation, the death
should be attributed to the underlying illnesses, not the sedation.
As requests for hastened death and sedation for intractable suffering
may have considerable personal, ethical, and legal ramifications, they should
not be dealt with in isolation, but rather with the input of trusted colleagues
and/or expert advisors. Clinical experience suggests that most requests for
hastened death will resolve if unmet needs are addressed.42
It also remains a fact that, as of October 2000, in all the United States
except Oregon, physician-assisted suicide is illegal. When physician-assisted
suicide requests are declined, full comfort care should continue and health
care professionals should continue to work closely in partnership with the
patient and family to minimize their suffering and optimize their opportunity
for meaningful and valued time together.
No matter how well families and professional caregivers are prepared,
the time of death can be challenging. Physicians can help families by preparing
them with information about what to expect, and what to do when death occurs.47 Families, including children, and caregivers may
have specific questions for the physician. Basic information about death may
be appropriate (eg, the heart stops beating; breathing stops; pupils become
fixed; body color becomes pale and waxen as blood settles; body temperature
drops; muscles and sphincters relax, so urine and stool may be released; eyes
may remain open; the jaw can fall open; and observers may hear the trickling
of fluids internally).47,48
When a physician lets family know about the death, the steps for communicating
bad news should be followed. Physicians should avoid breaking unexpected news
by telephone.4 Communicating in person provides
much greater opportunity for assessment and support. As visitors arrive, the
physician should spend a few moments to prepare them for what they are likely
When expected death occurs, the focus of care shifts from the patient
to the family, and those who provided care. Many experts assert that the time
spent with the body immediately after the death will help people cope with
their acute sense of loss.49- 51
Those present, including caregivers, may need the physician's permission to
spend the time they need to come to terms with the event and say their good-byes.
Even in the hospital, there is no need to rush. Those who need to touch, hold,
or even kiss the person's body should be encouraged to do so in the way they
feel most comfortable (while maintaining universal body fluid precautions).
As a visually peaceful and accessible environment may facilitate the acute
grieving process, the patient's body should be prepared for the family, with
any lines and machinery disconnected, catheters removed, and any mess cleaned
up to allow the family closer access to the patient's body with greater comfort.52,53
The physician, spiritual advisors, or other interdisciplinary team members,
particularly nurses, may be instrumental in orchestrating events to facilitate
the immediate experience of those present. Those who were not present for
the death may benefit from a recounting of how things went leading up to the
death and afterward. Grief reactions beyond each individual's cultural norms
suggest a risk of significant ongoing or delayed grief reactions.54 Desired religious rites and rituals should not be
Once family members have had the time they need to deal with their acute
grief reactions and observe their customs and traditions, preparations for
funeral or memorial service(s), and burial or cremation can begin. Some family
members may find it therapeutic to help bathe and prepare the person's body
for transfer to the funeral home or the hospital morgue. For many, such rituals
will be their final act of direct caring.
Depending on local regulations and arrangements, some funeral directors
will insist on the completed death certificate being present before they pick
up the body. All will require a completed death certificate to proceed with
any body preparation and registration of the death. To avoid delaying the
process, the physician who will complete the certificate should have ample
warning that one will be required.
For many, moving the body is a major confrontation with the reality
of the death. Some family members will want to witness the removal. Others
will find it too difficult and will prefer to be elsewhere. Once the body
has been removed and family members are settled, professional caregivers may
offer to assist them with some of their immediate tasks. They may offer to
notify other physicians and caregivers that the death has occurred so that
services can be stopped, equipment removed, and wastes disposed of. Local
regulations governing the handling of medications and waste disposal after
a death vary.
When family members are ready, professional caregivers can let the family
know how to reach them, then leave them to have some privacy together. A bereavement
card from the physician, attendance at the patient's funeral, and follow-up
telephone calls or visits to see how everyone is coping may be appropriate.55
To be effective in end-of-life care, physicians need to be able to recognize
grief and assist with appropriate interventions for patients, their family
caregivers, and themselves. Grief is the emotional response every person has
to loss.56 Throughout the course of a life-threatening
illness, patients and families confront many different anticipated, if not
actual, losses (eg, loss of functional capabilities, control, independence,
body image, dignity, relationships, sense of future, etc). Depending on the
perceived importance of the loss, their grief reactions may be pronounced.56- 58 Physicians should
have a basic understanding of grief reactions for those patients who seek
Normal grief reactions include a range of physical, emotional, and cognitive
behaviors that may or may not follow cultural norms.59- 61
Some people will make a conscious effort to deal with the loss. Others will
deny what is happening and avoid dealing with the loss. Some coping strategies
(eg, increased smoking, alcohol, or medication intake; overwork; or suicidal
ideation) may accelerate and even become destructive, especially in the face
of seemingly insurmountable loss. Patients experiencing grief may seek assistance
from their physicians for these symptoms. The 7-step approach can be used
to elicit the cause for the grief reaction and its perceived importance. If
grief is not recognized by the physician, misleading or useless diagnostic
studies or prescribing of medications may occur.
When grief reactions occur over long periods, are intense, or interfere
with the survivor's physical or emotional well-being, they become symptoms
of complicated grief.54,61 There
are 4 categories of complicated grief reactions. Chronic grief is characterized
by normal grief reactions that do not subside and continue over long periods
(normal grief lasts 6-12 months). Delayed grief is characterized by normal
grief reactions that are suppressed or postponed. In exaggerated grief, the
survivor may resort to self-destructive behaviors such as suicide. Finally,
in masked grief, the survivor is not aware that the behaviors that interfere
with normal functioning are a result of the loss.
The physician needs to be attuned to behaviors that might indicate complicated
grief, especially if these continue beyond 6 to 12 months.61
The survivor may not be able to speak of the deceased without experiencing
intense sadness. Themes of loss may continue to occur in every topic during
a clinical interview. Minor events may unexpectedly trigger intense grief
and sadness. The survivor may be unwilling to move possessions belonging to
the deceased. Sometimes the survivor will develop symptoms similar to those
of the deceased.54 When complicated grief is
suspected, referral for specialized help is warranted.
After a major loss, there are typically 4 tasks to complete before the
bereaved will effectively deal with their loss.55
These tasks apply to the many losses that precede the death, as well as to
the death itself. While the tasks are interdependent, they are not necessarily
completed in sequence. First, the bereaved must realize and accept that the
loss or death has actually occurred. Second, they need to experience the pain
caused by the loss. As this can be distressing, many who are bereaved try
to avoid the pain, and physicians may try to blunt it with medication. If
a minor tranquilizer is used, such as a benzodiazepine, it should only be
for a brief period.54 Third, they need to recognize
the significance of their losses and the changes to their lives. Finally,
as grief proceeds, the bereaved need to reinvest their energy into new activities
If grief reactions and coping strategies appear to be inappropriate
or ineffective and/or they have the potential to cause harm (eg, destructive
behaviors or suicide), they will need to be assessed and managed quickly.
The physician should consult someone, such as a social worker, chaplain, bereavement
counselor, psychologist, or psychiatrist, who is skilled in problematic loss,
grief, and bereavement care so that therapy can be instigated quickly to reduce
the risk of harmful/destructive activities.
A single clinical 7-step approach to communication can provide a helpful
framework for approaching many of the tasks that physicians find challenging
in end-of-life care. Effective application, as part of core end-of-life care
competencies,62 is likely to improve patients'
experiences of care. It may also enhance physicians' professional fulfillment
from satisfactory relationships of care.