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.
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
Tulsky JA. Beyond Advance Directives: Importance of Communication Skills at the End of Life. JAMA. 2005;294(3):359–365. doi:10.1001/jama.294.3.359
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