I think there is more than ever both the need and opportunity for us to “be there.”  While my list is not exhaustive, I think there are six major roles the family physician plays in caring for their patients near the end of life:

Giving bad news:  Even if you are not the first to give bad news, following up with a phone call or visit after a patient has received a dread diagnosis provides reassurance and comfort.  Remember it’s you the patient knows best and trusts.

Continuing care: Even if the cancer care becomes the domain of the oncologist, our patients have more than one disease and multiple needs.  Create a schedule of regular visits to be in contact with ongoing treatment and prognosis.  Address their other health problems as they come up and be an active contributor to addressing the primary one.

Symptom management: Regardless of the primary diagnosis, there are common symptoms in the advanced stages of chronic disease.  These include pain, shortness of breath, constipation, fatigue, and depression.  One or more of these is almost universal in the last months of someone’s life. Acknowledging and addressing these symptoms can be crucial to the patient’s function and comfort.

Facilitating goals of care:  Here is the area most likely not addressed by other physicians caring for our patients.  Most people in the United States who die are over 65 years and die of one of more of their chronic diseases.  We are trained in diagnosis and treatment of diseases, often omitting discussions of patient preferences, prognosis, and goals of care.  Every family physician should practice skills in identifying patient preferences, communicating about medical prognosis, defining and prioritizing goals of care (length of life, physical and mental function, comfort) and helping to implement a management plan consistent with the patient’s goals.  Prioritizing goals affects the interventions offered and recommended; this process is dynamic. Goals and therefore plans change with prognosis and patient wishes.

Making the hospice referral: Sometimes after eliciting patient goals, it becomes clear a hospice referral is appropriate.  While there are disease specific guidelines, with heart failure, COPD, and dementia it may be time for hospice when the patient no longer wants to go back to the hospital. It is not hard being the attending physician for your patient in hospice – they will help you, the patient, and their family.

Supporting caregivers: Chances are the patient’s caregiver is your patient too.  Do not forget caregiver needs as their role changes and much different skills are demanded of them.  Without this connection and the demands on their time and efforts, caregivers are not likely to ask for help and remain subject to anxiety, frustration, exhaustion, and depression.

We continue to provide care near the end of life. We can learn the skills, seize the opportunities, find value in this work and we will be appreciated.  Whom would you want tending to your health needs when the end of your life is near?