Educating our Patients about Life and the End of Life: Toward a Pedagogy of Dying

Abstract

There is an extensive literature on how physicians can best educate their patients about living healthierone might call it a "pedagogy of living." In this essay, I suggest that physicians develop a "pedagogy of dying" for their adult patients: educating them about how they can approach death with some measure of grace and dignity, as consistent with their wants as possible, and cognizant of the final reality we all face. This process happens in the ambulatory settings as part of ongoing care and precedes any serious illness or the crisis of hospitalization. I draw on known models for communicating effectively, my own practice experience, and the disciplines of palliative care and bioethics in asking physicians to consider developing such a "pedagogy of dying," a kind of anticipatory guidance toward aging, infirmity, and, ultimately, death. As physicians, we make a great number of recommendations to our adult patients about how they should live. These recommendations collectively create a "pedagogy of living": suggestions for living healthier lives. What I propose here, however, is for physicians to develop a "pedagogy of dying": a way of educating patients about how to approach their deaths with some measure of grace and dignity, as consistent with their wants as possible, and cognizant of the final reality that we all face.Much has been written-prudently and with sensitivity-about advance directives, physician orders for life-sustaining treatment, and do-not-resuscitate orders, 1-3 including suggestions on how to approach these issues as structural concerns embedded in the culture of medical practice.4,5 Advance care planning seeks to prepare patients and surrogates for making in-the-moment medical decisions. 6 There also exist excellent guidelines for approaching patients and their families at the end of life.7 Still, most discussions about death and the desired clinical response come quite late in the course of patients' lives-often too late for sensible dialogue to occur.When the end of life looms inevitable and not just as an abstract awareness, a whole host of social and emotional preoccupations overwhelm patients, families, and clinicians alike. It is important for us as physicians to proactively aid patients before the end of life to ameliorate the fear, loneliness, and uncertainly that often accompanies the dying process, especially in today's fragmented medical environment. Beyond the necessity of knowing know what end-of-life interventions are desired or appropriate, we have a responsibility to help people explore and come to terms with their own mortality well before it is "their time."There is ample space in the academic literature that describes communicative tools given to adeptly practicing a "pedagogy of living," 8 including several models for structuring clinical conversations and the dynamics of interpersonal engagement. 9,10

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