​Benjamin Li, M.D. is the Director of the Cancer Center, Division of Surgical Oncology, The MetroHealth System. Dr. Li shares his insights on patient conversations and end-of-life care with Clinical Connections.

Q: Dr. Li, how can physicians learn what matters most to patients about end-of-life care?

I’m delighted to see that this topic is now being taught in medical schools. That wasn’t always the case. At Metro, it’s also a part of our residency training. Being a physician is all about life-long learning and this includes learning about end-of-life care. There are many ways palliative and end-of-life-care are being incorporated into our life-long learning process. Peer group educational programs, continuing medical education programs and web-based seminars are available for physicians interested in palliative and end-of-life care. There are also symposiums and conferences devoted to this topic. On August 31, the MetroHealth Cancer Center will host our annual cancer symposium. This year, we have devoted it to palliative and terminal care, and we are delighted that Hospice of the Western Reserve will be part of it.


Q: At what point should conversations about goals of care begin?

In all honesty, there is not one optimal time. There are many complexities and every individual patient and family is different. There are many schools of thought on this topic, but hard data is lacking. We do know there are important considerations. In collaboration with Hospice of the Western Reserve, we are exploring some of these concepts. Developing a bond of trust with the patient early is essential. Introducing the topic of hospice too early is inappropriate, but introducing it too late or not at all is detrimental. 
Seventy-five percent of patients with terminal illnesses are currently dying in hospitals. This doesn’t honor what most people want for themselves. Introducing the topic when the prognosis indicates surgery and treatments are not going to be effective helps patients and their families get the full benefit from hospice and palliative care and addresses their needs in a respectful and compassionate manner.

Q:  How and when do you recommend introducing the topic of completing Advance Directives (ADs)?

First, physicians need to be comfortable. If they are well trained, at ease, and have a trusting relationship with their patient and loved ones, then a meaningful discussion about what the patient wants, what he or she is willing to give up, and ultimately, what’s most important to her/him can be thoughtfully and compassionately broached.

Q: Thinking about end-of-life care can be scary for patients and their families. How can physicians help normalize this topic? 

Well, first, we don’t want it to get to the point where they can’t speak for themselves. Whenever possible, we want to avoid placing the burden of decision-making solely on the family. Developing trust early with one’s patient leads to more thoughtful and compassionate discussions between the physician and patient. This will help ease fears and enable the patient to understand why communicating her/his end-of-life healthcare choice is so important. Having the choices documented takes the burden off the family. 

Q: Can you share a story that illustrates why helping patients identify a proxy and communicate their end-of-life care choices through the completion of Advance Directives earlier in the course of an illness is so important?

I remember a patient who was thinking about her ADs, but had not completed them. This patient had an advanced GI malignancy. She had completed both chemotherapy and surgery, had done well initially. Unfortunately, her cancer recurred. In a short interim, it had advanced to a point where further surgery and/or chemotherapy was not helpful. Before she could complete her ADs, she developed a complication. Her cancer had eroded into her bowel. She presented to the ER in extremis. Because of her perforated bowel, and without ADs, she was taken emergently to the operating room. Surgery on a cancer-perforated bowel in an abdomen full of cancer is not going to be successful. As a result, she ultimately passed away, weeks after being in the intensive care unit. This scenario could have been avoided if she had her ADs completed. 

Q:  Are there any final thoughts you would like to share?

The importance of education, the trust between physician and patient, and the need to be comfortable and compassionate in caring for terminal patients cannot be stressed enough. The reality is that we will all die someday. In the past, physicians may have viewed their inability to cure as a failure. It is not a failure. It is important for physicians to view terminal care as part of our responsibility to our patients and families, to help them transition through this final phase. When a cure is not likely, the focus needs to be about what patients and their families need and want. We owe it to our patients and their families so they can find the meaning and closure that we all deserve at the end of our lives.