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the burden of decision-making falls entirely on the family. This
burden is well known to cause harm: caregivers suﬀer negative
emotions of stress, doubt, and guilt which can last for years,
especially if an advance directive is not present (8). Caregivers
can also be wrong about patient preferences (9) and often opt
for more aggressive treatment (10)! While many caregivers may
be involved in making medical decisions for their loved ones at
the end of life, it should be noted that a living will may be more
beneﬁcial than a medical power of attorney alone when it comes
to making decisions about code status and limiting aggressive
treatment interventions (11), and the presence of a living will
reduces the emotional burden on caregivers (8).
Shared decision-making is a spectrum that ranges from patient choice to paternalism. "Viaticum" illustrates an attempt to
honor patient autonomy for an acute problem in scene 1 and a
clear medical recommendation that takes the whole person into
account in scene 2. Hard paternalism would be decision-making
without any input from patients or their loved ones and should
be avoided, just as uninformed patient choice without any physician input should be avoided. Ideally, medical decisions should
involve a collaboration between physician and patient: patients
should share their understanding of their medical problems and
what is most important to them given their situation (i.e., their
goals and values), and physicians should oﬀer treatment options
aimed at accomplishing those goals (and avoid treatments that
won't accomplish the goal).
At ﬁrst glance, this makes a lot of sense, but in practice it
can be diﬃcult to achieve without a framework to follow or
additional training in communication skills. While palliative
care as a medical specialty exists to support seriously ill patients
and help with diﬃcult conversations, the number of professionals practicing palliative care is small and growing slowly in
comparison to the need. Truthfully, all health care professionals who will someday take care of patients with serious illness
should achieve some measure of proﬁciency in serious illness
conversation skills by the time they ﬁnish training.
Fortunately, changes within medical training and the health
care system are supporting a greater focus on shared-decision
making and communication skills. Structured programs like
the Serious Illness Care Program (SICP) give health care providers a framework and the skills needed to engage in diﬃcult
conversations. SICP has grown out of a collaboration between
a leading palliative care expert, Dr. Susan Block, and renowned
surgeon Dr. Atul Gawande, as he wrote his bestselling book
Being Mortal. The Serious Illness Guide, a set of eight questions used to guide conversations with seriously ill patients,
aims to improve care by encouraging health care providers to
have more, earlier, and better conversations. Baylor Scott and
White is the ﬁrst health care system in the US to partner with
Ariadne Labs to fully implement the program across an organization of our size.
As a palliative care professional, I am frequently consulted
when providers are struggling with how to care when cure is

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not possible. This is never an easy situation, but a few basic and
universal principles can guide us through these conversations.
First, we must understand both the biology and biography of
our patient. Where is our patient in the trajectory of disease,
but also who and where is our patient in the story of his or
her life? Next, armed with that knowledge, we must utilize
both the art and science of medicine to recommend interventions we believe are most appropriate-not for the disease, but
for the patient who suﬀers with the disease. Finally, we must
communicate our recommendation carefully, for language truly
matters (12). Medicine well practiced is a team eﬀort, and if we
collectively continue to learn new skills (such as those embedded
in the SICP), then we will truly provide our patients and their
families with the most beneﬁcial treatments and highest level
of care that can be given.
-Laurel B. Kilpatrick, MD
Division of Supportive and Palliative Care
Scott & White Clinic, Temple, Texas
E-mail: laurel.kilpatrick@bswhealth.org
Fine RL, Michel JM. Viaticum. Proc (Bayl Univ Med Cent) 2017;30(4):471-
472.
2. Steinhauser KE, Christakis NA, Clipp EC, McNeilly M, McIntyre L,
Tulsky JA. Factors considered important at the end of life by patients,
family, physicians and other care providers. JAMA 2000;284(19):2476-
2482.
2. Barnato AE, Herndon MB, Anthony DL, Gallagher PM, Skinner JS,
Bynum JPW, Fisher ES. Are regional variations in end-of-life care intensity
explained by patient preferences? Med Care 2007;45(5):386-393.
3. Mending mortality. The Economist 2017(April 29);423(9038):45-48.
4. Council on Ethical and Judicial Aﬀairs, American Medical Association.
Guidelines for the appropriate use of do-not-resuscitate orders. JAMA
1991;265(14):1868-1871.
5. Bosslet GT, Pope TM, Rubenfeld GD, Lo B, Truog RD, Rushton CH,
Curtis JR, Ford DW, Osborne M, Misak C, Au DH, Azoulay E, Brody B,
Fahy BG, Hall JB, Kesecioglu J, Kon AA, Lindell KO, White DB; American
Thoracic Society Ad Hoc Committee on Futile and Potentially Inappropriate Treatment; American Thoracic Society; American Association for
Critical Care Nurses; American College of Chest Physicians; European
Society for Intensive Care Medicine; Society of Critical Care. An oﬃcial
ATS/AACN/ACCP/ESICM/SCCM policy statement: Responding to
requests for potentially inappropriate treatments in intensive care units.
Am J Respir Crit Care Med 2015;191(11):1318-1330.
6. Chung GS, Lawrence RE, Curlin FA, Arora V, Meltzer DO. Predictors of
hospitalised patients' preferences for physician-directed medical decisionmaking. J Med Ethics 2012;38(2):77-82.
7. Wendler D, Rid A. Systematic review: the eﬀect on surrogates of making
treatment decisions for others. Ann Intern Med 2011;154(5):336-346.
8. Shalowitz DI, Garrett-Mayer E, Wendler D. The accuracy of surrogate decision makers: a systematic review. Arch Intern Med 2006;166(5):493-497.
9. Narang AK, Wright AA, Nicholas LH. Trends in advance care planning
in patients with cancer: results from a national longitudinal survey. JAMA
Oncol 2015;1(5):601-608.
10. Torke AM, Sachs GA, Helft PR, Petronio S, Purnell C, Hui S, Callahan CM.
Timing of do-not-resuscitate orders for hospitalized older adults who require
a surrogate decision-maker. J Am Geriatr Soc 2011;59(7):1326-1331.
11. Fine RL. Language matters: "sometimes we withdraw treatment but we
never withdraw care." J Palliat Med 2007;10(6):1239-1240.
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