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Communication Along the Disease Trajectory

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    The value of end-of-life discussions is not solely psychological. In addition, aiding patients with end-of-life discussions through this kind of communication has an impact on health care costs. In a large study of people with advanced cancer, patients who reported having end-of-life discussions with their physicians (n = 188) had significantly lower health care costs than did patients who did not have these discussions (n = 415). This was demonstrated by a reduction in resuscitation, ventilator use, and intensive care stay. There was no difference either in survival time or in the likelihood of receiving chemotherapy for patients who discussed end-of-life preferences with physicians (n = 75) and those who did not (n = 70). Higher costs were associated with worse quality of life at death, as rated by the patient's caregiver (hospice nurse or family member).[32][Level of evidence: II]

    Patients facing death have myriad concerns that include leaving children and other loved ones behind; decline in the socially based aspects of one's identity;[33] the end of being able to fulfill normal roles; fear of burdening loved ones;[34] loss of control; deterioration in personal appearance; needing help with intimate personal care and routine activities of daily living; worries about mental awareness;[35] pain and management of symptoms; quality of life; dignity;[36] achieving a sense of completion; having a good death; and abandonment. During transitions, patients want their oncologists to provide biomedical information, show that they care about them as individuals, and balance hope with realism. One study [37] identifies several communication strategies to accomplish this, including "ask-tell-ask" and "hope for the best, prepare for the worst." A number of patients are grateful for the opportunity to talk about questions of death, though they often have few opportunities because many patients find that the medical staff is afraid of or uncomfortable with talking about death and dying,[31] which exacerbates feelings of isolation and separation.

    Saying goodbye to patients is an area discussed in an article that provides practical suggestions for communicating with the patient at the end of life.[38] The authors suggest that saying goodbye is an important way for the oncologist to achieve closure with the patient by acknowledging the importance of the relationship and expressing appreciation to the patient.

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