# 065 Establishing End-of-Life Goals: The Living Will Interview, 2nd ed

FAST FACTS AND CONCEPTS #065 PDF


Author(s): Bruce Ambuel PhD

Introduction “When a person faces a fatal disease that is likely incurable, he or she faces specific decisions not only about medical treatment but also about broader, existential issues concerning the best way in which to spend his or her remaining time.” (Hammes 1998)

Doctor-patient discussions about end-of-life treatment are often framed as a choice between “medical treatment vs. treatment withdrawal.” When framed in this manner, treatment withdrawal is a negative choice that often implies giving up, abandonment, not giving the doctor a chance to do his or her job, and not caring; this option would seem to be no option at all.

Bernard Hammes PhD suggests that the physician can reframe the doctor-patient dialogue about end-of-life treatment by starting a conversation with the patient focused on the question “How can we help you live well?” The goal of the living well interview is to elicit the patient’s perspective regarding how they want to spend their remaining time. Treatment decisions are then discussed within this broader context of patient goals and hopes. Treatments become tools for achieving patient goals.

The Living Well Discussion

  • When: Begin soon after the diagnosis of a life-limiting condition.
  • Who: Physician and patient with support from others: family, nurse, chaplain, etc.
  • How: Begin by expressing a need and interest to understand the patient’s views. The physician’s initial goal is to develop a broad understanding of the patient’s hopes and goals, not to develop a specific medical plan. Specific treatment decisions are made after the patient and health care team have developed an understanding of the patient’s broader goals.
  • What to say: Given what we now know about your medical condition…
    • How can we help you live well? What makes you happy?
    • Maintaining or fulfilling what activities or experiences are most important for you to feel your life has quality, or for you to live well?
    • What fears or worries do you have about your illness or medical care?
    • If you have to choose between living longer and quality of life, how would you approach this balance?
    • What needs or services would you like to discuss?
    • What do you hope for your family?
    • Are there any special events or activities that you are looking forward to?
    • What sustains you when you face serious challenges in your life?
    • Do you have religious or spiritual beliefs that are important to you?
    • In what way do you feel you could make this time especially meaningful to you?

References

  1. Hammes BJ, Bottner W, et al. Expanding frames…opening choices: reconsidering conversations about medical care when cure is not possible. Illness Crisis Loss. 1998; 6(4):3252-56.
  2. Hammes BJ, Rooney BL. Death and end-of-life planning in one midwestern community. Arch Int Med. 1998; 158:383-390.

Fast Facts and Concepts are edited by Drew A Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For more information write to: drosiell@mcw.edu. More information, as well as the complete set of Fast Facts, are available at EPERC: www.eperc.mcw.edu.

Version History: This Fast Fact was originally edited by David E Weissman MD. 2nd Edition published July 2006. Current version re-copy-edited April 2009.

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Ambuel B. Establishing End-of-Life Goals: the Living Well Interview, 2nd Edition. Fast Facts and Concepts. July 2006; 65. Available at: http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_065.htm.

Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

ACGME Competencies: Interpersonal and Communication Skills, Patient Care

Keyword(s): Communication