The Unspoken: Why Physicians Often Avoid End-of-Life Conversations

End of life

In medicine, where healing and prolonging life are paramount, there exists a reluctance to discuss one of life’s inevitabilities: death. Despite the profound impact end-of-life conversations can have on patient care and quality of life, physicians often hesitate or avoid the topic altogether. This avoidance stems from various factors, including personal discomfort, fear of causing distress, lack of training, time constraints, and systemic barriers.

The Weight of Responsibility

Physicians are trained to save lives, to fight against disease with all available resources. Confronting the reality of death can feel like a personal defeat, a reminder that, despite our best efforts, we have limits. This psychological burden can be particularly heavy for those in specialties where many patients are facing life-threatening illnesses. As physicians and healthcare providers it is important to remember that although it is not always possible to cure disease, we can always provide comfort. When we remind ourselves that providing comfort and support to dying patients is part of who we are and what we were trained to do, both the patient and physician will feel more at ease during these discussions.

Fear of Causing Distress

Another common concern among physicians is the fear of causing emotional distress to patients and their families. Death is a deeply sensitive topic, laden with fear, sadness, and uncertainty. Physicians may worry that initiating end-of-life discussions could unnecessarily upset their patients or prematurely diminish hope. As physicians, it’s important to remember that it is at the end of life that patients and families need us the most. Rather than viewing these conversations as an undesirable obligation, we should view them as a profound privilege and an important responsibility. Guiding a family through some of life’s most heartbreaking conversations, yet still emerging as a source of comfort and compassion in their eyes, creates an indelible bond. When delivered with empathy and grace, bad news need not portray the bearer as the villain, but as a dedicated and trusted supporter. Though bearing these painful responsibilities may tax our emotional strength, the memories crafted in those anguished hours among those grieving will far outlast the fatigue.

Empowering Physicians Through Education and Support

Despite the importance of end-of-life conversations, medical education historically has provided very limited training in this area. When training is included in the curriculum, it frequently consists of a few short lectures that refer to obsolete models used decades ago. The reality is that the vast majority of physicians lack the skills and confidence to handle delicate discussions when they enter practice and therefore have no other recourse than to learn through observation of more experienced physicians, many of whom may not have received training themselves. Medical schools and residency programs must incorporate more comprehensive training in end-of-life communication skills. Through available training courses such as the “Breaking Bad News Program”, The Orsini Way has changed the way physicians view difficult discussions. Equipping physicians with the communication skills needed to navigate these conversations, can help ease our anxiety and help our patients when they need us the most.

Time Constraints and Priorities

In a healthcare system that often involves packed schedules and competing priorities, time is a precious commodity. End-of-life conversations require patience, empathy, and unhurried dialogue—luxuries that are often in short supply. As a result, physicians may prioritize tasks that feel more urgent, relegating discussions about end-of-life care to the back burner. By recognizing that end-of-life discussions are one of the most important responsibilities of the day, physicians should take the time to alert his/her staff that they should not be interrupted except for emergencies. Studies have shown that when a provider takes the time to have an open and honest discussion, answering questions and addressing concerns, it actually saves time thereby debunking the myth that talking to patients takes too long. 

Cultural and Systemic Barriers

Beyond individual reservations, systemic barriers within the healthcare system can also impede end-of-life conversations. Fee-for-service models incentivize aggressive treatments over palliative care, creating a culture that prioritizes intervention over acceptance. Additionally, healthcare policies and reimbursement structures do not adequately support the time and resources needed for comprehensive end-of-life discussions. Healthcare administrators must prioritize communication skills, allowing sufficient time with patients to positively impact their care. Be on the lookout for a new episode of Difficult Conversations: Lessons I Learned as an ICU Physician with Dr. Jess Daigle where we will talk specifically about these issues. The more we discuss this difficult topic, the better we can learn to comfort each other.

Breaking the Silence: A Call to Action

Despite these challenges, the importance of end-of-life conversations cannot be overstated. Research has shown that patients who engage in advanced care planning experience better quality of life, reduced healthcare costs, and increased satisfaction with their care. By addressing fears, providing training, and restructuring healthcare systems to prioritize patient-centered communication, we can break the silence surrounding end-of-life care.

Shifting Healthcare Policies and Practices

Healthcare systems must also implement policies that support and incentivize proactive end-of-life discussions. This may involve revising reimbursement structures to compensate providers for time spent on advanced care planning or integrating palliative care services into standard practice.

Promoting a Culture of Openness and Acceptance

Finally, we must work to shift societal attitudes toward death and dying. By destigmatizing conversations about mortality and promoting acceptance as a natural part of the human experience, we can create a culture where end-of-life discussions are embraced rather than avoided.

In conclusion, the avoidance of end-of-life conversations among physicians is a multifaceted issue with far-reaching implications for patient care and quality of life. By addressing the underlying fears, improving training, and restructuring healthcare systems to prioritize patient-centered communication, we can empower physicians to engage in these difficult conversations with confidence and compassion. Only by breaking the silence surrounding end-of-life care can we truly honor the dignity and autonomy of every patient, from diagnosis to the final moments of life.

Follow-up Note

The Orsini Way has had the privilege to have spoken with many experts on the Difficult Conversations: Lessons I Learned and an ICU Physician Podcast regarding End-of-Life conversations. Guests like Hospice Nurse Julie and Dr. BJ Miller have illuminated to us the many ways we can deliver compassionate care at the end of someone’s life. Most recently, we discussed how end-of-life care is handled so differently in Canada with special guest Dr. Samanatha Winemanker.

Dr. Anthony Orsini

Dr. Anthony Orsini

Dr. Anthony Orsini is a practicing neonatologist and founder of The Orsini Way, a training program that shows healthcare professionals a way to communicate that enhances patient satisfaction and improves outcomes. He is also the author of “It’s All In The Delivery: Improving Healthcare Starting With A Single Conversation” and his podcast: Difficult Conversations – Lessons I Learned an ICU Physician.

Share this post!


Get the latest posts from Dr. Orsini in your Inbox.

This field is for validation purposes and should be left unchanged.