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Perspectives on Care at the Close of Life
Clinician's Corner
July 20, 2005

Beyond Advance Directives: Importance of Communication Skills at the End of Life

Author Affiliations

Perspectives on Care at the Close of Life Section Editor: Margaret A. Winker, MD, Deputy Editor, JAMA.


Author Affiliations: The Center for Palliative Care and the Department of Medicine, Veterans Affairs Medical Center and Duke University, Durham, NC.

JAMA. 2005;294(3):359-365. doi:10.1001/jama.294.3.359

Patients and their families struggle with myriad choices concerning medical treatments that frequently precede death. Advance directives have been proposed as a tool to facilitate end-of-life decision making, yet frequently fail to achieve this goal. In the context of the case of a man with metastatic cancer for whom an advance directive was unable to prevent a traumatic death, I review the challenges in creating and implementing advance directives, discuss factors that can affect clear decision making; including trust, uncertainty, emotion, hope, and the presence of multiple medical providers; and offer practical suggestions for physicians. Advance care planning remains a useful tool for approaching conversations with patients about the end of life. However, such planning should occur within a framework that emphasizes responding to patient and family emotions and focuses more on goals for care and less on specific treatments.

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