For most of his medical career, Kamloops oncologist Dr Ardashes Avanessian tended to postpone end-of-life discussions with his patients, often waiting until their disease was quite advanced.
“It’s a difficult thing to talk about because it’s so emotionally laden and it takes time and you have to be in the right mood,” says Avanessian, who adds that his medical training didn’t prepare him for taking responsibility in that area.
“I knew the discussion had to happen, and it always bothered me when I didn’t get around to it,” says Avanessian. “I felt like part of my practice was missing, and I felt unfinished with my patients as they went through this phase and moved to another physician.”
In March 2011 Avanessian participated in a Practice Support Program (PSP) module about end-of-life (EOL) care, where he learned about the Ministry of Health’s support for advance care planning and about the resources available for both physicians and for patients and family members confronting end-of-life issues.
“Before I attended the learning session I had scattered ideas about these things, but this module helped me understand what’s available, what tools we can use, and how to approach patients for a discussion about their death without it becoming too emotional,” says Avanessian.
Kamloops physiatrist Dr Jill Calder has also participated in the PSP’s EOL learning module, although initially as a resource person involved in rolling out the module. In her practice as a rehabilitation specialist caring for patients with neurodegenerative disorders, Calder often works to ensure her patients get the equipment and other support they need to optimize their quality of life. However, says Calder, “Whenever you get involved in something you end up learning other things.” In her case, that included introduction to the My Voice document, and to details about the province’s advance care planning initiative.
“The EOL program has an incredible library and collection of resources—materials that you wouldn’t necessarily know about,” says Calder. “The PSP brings that all together under one banner.”
Calder credits the EOL module with solidifying what she knew from her own practice and then organizing it systematically and providing well-defined terminology. She also appreciates the EOL algorithm, especially in her work with amyotrophic lateral sclerosis (ALS) patients, who typically spend from 2 to 10 years in her care.
“The algorithm gives me a framework I can use as a way to approach what will be a pretty long commitment,” says Calder. “I used to have a filing cabinet full of reference and referral documents to various agencies—now the algorithm is always open on my desktop.”
For some of her referrals, Calder says she has to be prepared to engage in the discussion of advance care planning right from the start. For example, an ALS or other complex neurodegenerative patients might tell her they don’t want to be put onto a ventilator. However, the patient’s family might have different ideas. For such situations, Calder says she’s grateful for the provincial advance care planning guidelines, which clearly spell out the medical decision-making process for patients and physicians.
Since completing the EOL workshop, Dr Avanessian has found he no longer worries about EOL discussions with his patients, or about how long they might take.
“Each time I face this situation now, I feel more and more prepared,” says Avanessian. “I’m able to present patients with the My Voice material and I tell them they should be clear about their wishes, and I let them know what’s out there to help them develop an advance care plan.”
Avanessian also helped organize a 3-hour EOL summary workshop for his colleagues at the Kamloops Cancer Centre and says he sees the difference it has made in the clinic.
“We are all having more discussion about end of life with our patients, and we’re using the pamphlets and advising them about advance care planning, so in these ways the pattern of our practice at the cancer clinic has changed quite considerably over the past year.”
—Ken Seethram, MD, FRCSC, FACOG, Co-Chair, Specialist Services Committee
New SSC fee: Specialist Advance Care Planning ($40)
This fee is intended to support advance care planning discussions, development and coordination with patients with chronic medical illness, complex comorbidities, deteriorating quality of life, or end-stage disease state. Details can be found by visiting the SSC website at www.sscbc.ca.
This article is the opinion of the SSC and has not been peer reviewed by the BCMJ Editorial Board.
Above is the information needed to cite this article in your paper or presentation. The International Committee
of Medical Journal Editors (ICMJE) recommends the following citation style, which is the now nearly universally
accepted citation style for scientific papers:
Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.
About the ICMJE and citation styles
The ICMJE is small group of editors of general medical journals who first met informally in Vancouver, British Columbia, in 1978 to establish guidelines for the format of manuscripts submitted to their journals. The group became known as the Vancouver Group. Its requirements for manuscripts, including formats for bibliographic references developed by the U.S. National Library of Medicine (NLM), were first published in 1979. The Vancouver Group expanded and evolved into the International Committee of Medical Journal Editors (ICMJE), which meets annually. The ICMJE created the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals to help authors and editors create and distribute accurate, clear, easily accessible reports of biomedical studies.
An alternate version of ICMJE style is to additionally list the month an issue number, but since most journals use continuous pagination, the shorter form provides sufficient information to locate the reference. The NLM now lists all authors.
BCMJ standard citation style is a slight modification of the ICMJE/NLM style, as follows:
- Only the first three authors are listed, followed by "et al."
- There is no period after the journal name.
- Page numbers are not abbreviated.
For more information on the ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals, visit www.icmje.org