Looking beyond translation--integrating clinical research with medical practice.

1657 of-life conversations should be treated like any other competency, such as placing a central line or choosing appropriate antibiotics for pneumonia. An attending physician should model the skill, then watch trainees and offer feedback. Prognostication should similarly become a required skill. For instance, every initial admission of a seriously ill patient should include an assessment of prognosis alongside the plan for each organ system. Assessments should be discussed on rounds, and residents should be required to follow up to determine their accuracy. Of course, leading these conversations requires some skills that are difficult to teach, such as intuiting the responses of patients and families. Nevertheless, Kenneth Prager, director of clinical ethics at Columbia University Medical Center, says education remains imperative. He categorizes trainees into three groups: naturally good communicators, poor communicators, and a middle third who simply need proper instruction. Some attendings model these conversations for their teams and offer tangible advice. For instance, recognizing our tendency to shy away from death, Aaron Waxman, an intensivist at Brigham and Women’s Hospital, insists that each conversation include the words “death,” “dying,” and “dead.” Rather than try to dissuade patients from choosing resuscitative measures by stressing their potential brutality, Waxman chooses to focus on ways the physician can help to promote comfort. Through his example, he teaches residents that patient autonomy is not synonymous with endless choice. These conversations won’t get any easier. The population is aging. Hospitalists have assumed the care of patients who would once have been followed by their longtime physicians. Work-hour reform increasingly erodes residents’ relationships with inpatients. And with medical advances such as extracorporeal membrane oxygenation, ventricular assist devices, and transplantation, there’s almost always something else we could offer. Franz Ingelfinger, a former editor of the Journal who died of esophageal cancer, wrote an essay that the Journal published posthumously, in 1980, about what he sought from his own physicians at the end of life. He wrote, “A physician who merely spreads an array of vendibles in front of the patient and then says, ‘Go ahead and choose, it’s your life,’ . . . does not warrant the somewhat tarnished but still distinguished title of doctor.”