Palliative care involves hard conversations

 JAMA has a viewpoint by several palliative care physicians reflecting on why they are sometimes "fired" by their patients, i.e. why patients with (potentially) terminal illnesses may stop talking to them.  The reasons range from not necessarily agreeing that their illness is terminal (their other physicians may be conveying more optimistic messages), to finding that the patient's thoughts  about ending their lives are documented in their medical record.

Why Good Palliative Care Clinicians Get Fired  by Abby R. Rosenberg, MD, MS, MA1,2; Elliot Rabinowitz, MD1,2; Robert M. Arnold, MD  JAMA. Published online April 14, 2025. doi:10.1001/jama.2025.4353

 
"Even the most seasoned palliative care clinician gets fired. In the past year, one of us was fired after asking whether a patient endorsing suicidal ideation had access to a gun; the patient requested not to see the palliative care team because we asked intrusive questions and documented the encounter. One of us was fired after supporting a family’s decision to discontinue life-sustaining therapies for their loved one with multisystem organ failure; the primary intensivist suggested palliative care overstepped in discussing options for which the family (and clinical teams) was not ready. And one of us was fired after sharing the impression that a patient with cancer was dying; the family suggested they preferred the oncologist’s version of a more hopeful future.

Although many health care clinicians have been fired by a patient or family, palliative care clinicians may be at increased risk for dismissal.1,2 We invite difficult conversations, confront people with news they prefer to avoid, and encourage otherwise taboo topics such as human frailty and death. Our focus on what may go wrong differs from other clinicians’ optimism and may be unwelcome to patients and health care teams alike. We acknowledge emotional vulnerability, explore uncertainty, uncover fears, and describe a future in which patients make difficult choices about how they live and how they die."