The necessary discussion that’s often hard to have

Issue: BCMJ, vol. 56, No. 4, May 2014, Page 168 President's Comment

portrait of William Cunningham

This may seem like an unusual topic for my final president’s comment, but it’s a topic that will affect every one of us at some point in time. And I think I can safely say that we all want the same thing, whether for a patient, a loved one, or ourselves. That one thing is a good death.

The reason I bring it up now is because it’s being talked about at all levels (this article does not discuss physician-assisted death, currently being reviewed by the federal government). Advance care planning is being promoted by Doctors of BC—we’ve just released a policy paper on the subject—it’s being debated by the CMA among physicians and at public forums across the country (the second of five forums was held in Vancouver at the end of March with 225 interested members of the public participating), and the media are talking about it—most notably in a series in the Globe and Mail to which we contributed.

So what would a good death look like? The details might be different for everyone, but generally speaking it comes down to quality of life and the ability to die on our own terms. It requires putting some thought into it, developing a plan, and letting family and loved ones know.

In our recent policy paper, It’s Time to Talk: Advance Care Planning in British Columbia, we talk about the importance of a physician-initiated discussion with patients about planning for end of life as a standard of care—regardless of age, life stage, or health status, because you never know when a crisis will occur.

Our research into this topic suggests that when physicians initiate this discussion with their patients the conversation becomes normalized, making it easier to start the planning process. But we realize there are challenges for doctors. Early in our medical education we associate patient survival with success, so it’s no surprise that as doctors we have difficulty discussing death and dying with patients. As difficult as it is, talking about a plan for end of life is important, and the benefits of having this difficult conversation far outweigh the risks of not having it.

Despite the advantages of having an end-of-life plan, an extremely small percentage of Canadians (about 3%) have taken the time to develop one. There are myriad reasons why people delay discussing the end of their own life or that of a loved one, but evidence shows when discussions about values, goals, and wishes occur, it is better for everyone. For patients, having a plan can greatly reduce their anxiety; for family members, it eliminates second-guessing and eases the bereavement process; and for doctors, when we are aware of end-of-life goals we know our patients are being treated according to their wishes, and that puts us in a better position to support them and their families.

Doctors of BC makes four commitments and four recommendations based on the research for the policy paper. For example, we support physicians in identifying transition periods in patients’ lives to prompt them to initiate or revisit advance care plans, collaborating with government to ensure all health care providers have access to appropriate patient information, and continuing to support training and making resources available to doctors to assist them. And we recommend that doctors include in their consultation notes details about transition in health status as a standard of communication for all high-needs patients, the integration of advance care plans with patient records, and advance care planning as part of the required standard of care for patients with chronic or complex illness.

Our policy paper can be found on the Doctors of BC website at As well, more information on planning for end of life can be found on the Ministry of Health website at

Finally, advanced care plans shouldn’t just be for our patients. We need to remember our own family members, as well as ourselves. A good place to start is to ask yourself the question: What would I want the doctor to know if I (or a loved one) suddenly found myself in the ER, unconscious, and perhaps on life support? Wouldn’t you want the advance care plan to already be in place?
—William Cunningham, MD
President, Doctors of BC

William Cunningham, MD, CCFP, CCFP (EM). The necessary discussion that’s often hard to have. BCMJ, Vol. 56, No. 4, May, 2014, Page(s) 168 - President's Comment.

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