When Doctors Need Email Reminders to Talk to Patients About Death

By Lindsay Abrams

Another way we're making sure people have end-of-life care directives

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billaday/Flickr

You know how if someone emails you over and over, and doesn't stop until you finally respond or just go ahead and do what they've been asking you to, it's really annoying, but also a pretty good strategy on their part because they ended up getting what they wanted?

The same thing, it turns out, works with doctors. Only in this case what they're being nagged about is having an important conversation with terminally ill patients that, let's be honest, they shouldn't have been avoiding or forgetting in the first place.

The number of patients with incurable cancer whose charts indicate whether or not they want to be resuscitated can be doubled, a new study in the Journal of Clinical Oncology found, provided doctors are sent emails reminding them to ask.

Per national guidelines, this conversation is supposed to occur when a patient's prognosis is less a year.

Barring their ability to set up a Google alert for every time a patient's given 12 months or fewer to live, researchers at the Massachusetts General Hospital cancer center in Boston rigged a system where each time a patient began a new round of chemotherapy, their oncologist's inbox was spammed with messages reminding them to have The Talk. The emails got right to the point, beginning: "Your patient has recently been diagnosed with incurable lung cancer. If you have not already done so, this may be an appropriate time to begin a dialogue about his preferences for care at the end of his life."

Doctors who ignored or deleted the first email would continue to be inundated with reminders until they had filled out the section of their patient's electronic health record that dealt with their final wishes.

The results were encouraging because, hey, here's a simple and easy-to-implement system that can jump-start something that isn't happening nearly as often as it should -- pre-email alerts, fewer than 15 percent of the patients used as a control had documented their wishes. That said, the ultimate outcome of the emails was that after a year, a third of patients had their decision clearly stated in their electronic health records. That leaves the majority of the 100 test subjects -- people with incurable lung cancer -- for whom the end-of-life area of their file remained blank.

If a discussion isn't had, patients will end up being subjected to aggressive life-saving measures they never asked for. Resuscitation efforts can be emotionally traumatizing for everyone involved, not to mention costly. Most people, once they've had everything involved explained to them, end up choosing not to have hospital staff attempt to prolong their life.

A 2012 report from the California HealthCare Foundation found that, while 80 percent of people said that if they were seriously ill, they'd want to discuss their end-of-life options with their doctor, only 7 percent had actually had this conversation.

When the conversation does happen, according to an editorial that accompanied the email study, it's usually during the stressful, painful, and confusing final hours of a patient's life. The decision is wrested from the patient -- or from a distressed family member called upon to act on their behalf -- without anyone having the time to fully consider the implications.

A paradigm change seems urgently needed here, as places like The Conversation Project are trying to make the early and often discussion of end-of-life wishes more common practice. In the meantime, we'll just need to hope doctors don't figure out how to use their spam filters.

This article available online at:

http://www.theatlantic.com/health/archive/2013/01/when-doctors-need-email-reminders-to-talk-to-patients-about-death/266844/