Mastering Difficult Family Conversations in Surgical Care

Cue Cards: Effective Words for End of Life

Care Goals and Treatment Priorities: Explaining Comfort Care

Try Saying This

Avoid Saying or Doing This

“We always hope for the best, but we need to think about what is best for Beth right now.”
“We may be at the point when it makes sense to change the goals of care from prolonging your mom’s life through artificial means, thinking she might get better, to making her comfortable so she can rest more easily and die peacefully.” / “Do you want us to keep doing everything we can?” (Is too vague, implies an “all or nothing” approach. It is difficult for families to elect to “do nothing.”)
“We could continue with [xyz treatment options], or change the goals of care to ‘comfort care.’”
“Some of the complications of continuing current treatment are (e.g.): being on the ventilator until she dies; suffering from infections; taking drugs with various side effects; dealing with the discomfort of catheters in her body to give fluids, to remove urine; the stress of kidney dialysis or other life supports which require hospital treatment or long-term skilled nursing care; and continued decline in her thinking, memory, and ability to interact with you and the world.”
“’Withdrawing treatment’ doesn’t mean we stop caring for your mom. It means we stop procedures, such as [feeding tubes, dialysis, etc.] that can’t really cure her and are physically stressful for her.” / “Withdrawing care”
“Stopping care”
“Pulling the plug”
“Comfort care allows people to die a natural death. It means we provide a type of pain relief that would ease her death and other drugs to alleviate anxiety and additional discomforts that patients feel when dying.” / “We would take away her pain.” (May lead to the family wondering why you are allowing her to be in pain now.)

Care Goals and Treatment Priorities: Explaining Code Status (Module 4)

Try Saying This / Avoid Saying or Doing This
“Have you heard the terms, ‘DNR, DNI? Do you know what we mean when we ask you about your mom’s ‘code status?’” / “So what do your want her code status to be?”
“’Do Not Resuscitate’ means if your mom’s heart were to stop, we would not give her drugs to restart it, or administer electronic shocks, or push up on down really hard on her chest.” / “DNR means we would just let her die.”
“CPR is a procedure that was not intended or created to reverse final stages of an otherwise irreversible disease.”
“Unlike TV, where everyone seems to recover after being resuscitated, in real life only about 8% of patients survive for more than a month, and only 3% of these lead a mostly normal life.”
“’Do Not Intubate’ means that if your mom were to stop breathing on her own, we would not put a breathing tube down her throat to pump oxygen into her lungs.” / “DNI means we would just let her die.”
“Families also may choose to stop forcing their loved one to eat and drink. Doing so may seem inhumane, but these substances prolong dying and can make dying feel more uncomfortable.”
“Families in your situation also may choose to stop administering antibiotics, as they can no longer help.”
“[If asked] What is likely, after we start ‘comfort care,” is that…[explain process of dying].”
“We would continue to alleviate her pain and add other drugs to reduce anxiety, throat discomforts.”

Care Goals and Treatment Priorities: Family Decision Making (Module 4)

Try Saying This / Avoid Saying or Doing This
“Have you had any discussions with your mother about her wishes at the end of life?
“Does she have an advance care directive, or living will? Have you and she talked about what it says?” / “I assume you wish us to follow the health care directive forwarded to us from her internist?”
“What do you think your mother would want to happen now? What would she advise you, if she were able to speak?”
“You don’t have to make this decision right away.”
“What questions do you have?”
“How can I help you?”
“Would you like to confer with other relatives or family friends?”
“Does your mom belong to a spiritual community? Would you like to speak with the hospital chaplain or other person of faith?”
“May I call the palliative care nurse / social worker to talk with you about hospice?” / “I don’t know who can help you at this point; perhaps you should ask the nurse.”
“I don’t feel comfortable giving you my opinion, as the decision is yours.”
“I can give an opinion, but the decision is yours.”
“Whatever you decide, we will support you and Beth through this process.”
[If faced with unreasonable demands from the family for a clearly futile case]: “Unfortunately, I would not be able to meet your expectations, so let me offer to transfer her care to another provider / facility.”