There are specific skills that are central to successful palliative care. PCPs can learn these skills and include them in their practice. PCPs can progress to a level of mastery through which they empower patients to make informed end-of-life decisions about care, and improve provider satisfaction with the care delivered.

GIVING BAD NEWS AND PROGNOSTICATION

A provider’s initial contact with a patient who is learning of a life-altering diagnosis can be difficult. Learning to communicate bad news is essential to caring for patients. Like Elizabeth Kübler-Ross’s stages of grieving (1997), accommodating a new diagnosis may progress through stages, through which patients may begin to consider a new set of options. Although there are many models for delivering bad news (Baile et al., 2000; Vandekeift, 2001), the common threads include providing a private and comfortable space; limiting interruptions; establishing the patient’s level of understanding; explaining the context of the current discussion; and communicating the specific diagnosis clearly, simply, and in a language the patient understands. After the news or diagnosis has been delivered, the clinician must respond to the patient’s concerns and questions and establish a plan for moving forward. Periods of quiet reflection may occur, or outbursts of grief. People have a huge variety of emotional reactions to receiving bad news. They may be sad, angry, have difficulty expressing feelings, or seem inappropriately unconcerned. Providers must learn to deal with each of these responses. Remembering that the patient’s reactions are directed at the diagnosis and not at the provider is important. Providers can reflect back the emotion, thereby validating the patient’s experience. Each patient brings to the care relationship an individual set of characteristics that influence how he or she understands and processes medical information. Previous experiences, ethnicity, religious beliefs, and character traits all affect a person’s ability to cope with bad news. Using clear language and avoiding complex medical jargon improves patient understanding. Encouraging patients to ask questions and to restate the information in their own words will ensure that they have grasped the central information. The provider must continuously gauge the patient’s responses and need for clarification and support. Providers may not realize that there are misunderstandings unless specific questions are asked and patients are asked to restate the diagnosis in their own words. Even experienced clinicians find that patients have not understood the implications of specific results or prognoses despite discussions. Effective listening skills and clarification are critical. Providers will need to revisit these conversations throughout the progression of illness.

Prognostication is the skill of giving prognosis. Not a routine part of provider education, prognostication is one of the most important and valued tasks a provider performs. Patients want and need information about prognosis and ultimately the expected time until death. Understandably, providers find these questions difficult to answer, in large part because it is difficult to know when exactly a person will die (Christakis & Lamont, 2000). Aggregate data of 5-year survival often may not help in determining the time until an individual’s death. Acknowledging the uncertainty inherent in making predictions is essential to maintaining patient and family trust. However, providers have a responsibility to give patients considered opinions about prognosis, illness progression, and realistic life expectancy. These estimates are often expressed in minutes to hours, hours to days, days to weeks, or weeks to months. Health care professionals are educated and trained for many years to acquire experience that patients need to inform decisions about care. While it is painful as a provider to forecast death, patients will ask, and will usually find an honest response a relief. Prognostication allows patients the opportunity to appropriately plan for themselves and their families.

Through experience, providers become more skilled at eliciting unspoken concerns and tailoring information to each patient. Even novice clinicians can employ active listening techniques and a calm demeanor to deepen patient–provider discussions.

ADVANCE CARE PLANNING

Throughout the course of caring for a patient with a life-limiting illness, the PCP will have many opportunities to discuss patient wishes. Guiding patients to establish goals of care cannot be overestimated. Defining goals of care is the heart of providing palliative care. It facilitates true patient-centered care. Throughout the process, it is important to remember that palliative care intends neither to hasten death nor prolong life, but rather aims to support the patient and family through the process of living with an illness and dying with dignity. Advance care planning is the process of providing patients with a voice for their choices about specific interventions, whether via a health care proxy (a person) or living will (a document). Advance care planning allows patients to decide whether the benefits of particular interventions outweigh risks, and whether aggressive interventions and invasive procedures align with goals of care.

It may be easiest to start by ascertaining the patient’s surrogate decision maker or health care proxy. “If you are not able to speak for yourself, who would you like to make decisions for you?” is a common first question. The conversation then leads directly into finding out what, if anything, the patient has discussed with that person and allows the provider to introduce the idea of planning for death as well as living with illness. Further discussion allows the patient to ask questions and express wishes about life-sustaining therapies such as artificial feeding, cardiac resuscitation, and intubation. It is incumbent on the provider to provide information about likely outcomes of these treatments, as the public perception of benefit may be different from the providers’ reality, or the evidence to support the treatment (Diem, Lantos, & Tulsky, 1996; Girotra et al., 2012).