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Checklist theory used in creating end-of-life talk guide

Doctors are notoriously bad at talking to dying patients, but could a simple checklist change that?

That is the premise of a Boston project aimed at improving end-of-life care by providing doctors with a template for communicating with patients and their families.

“I’m afraid of being the bad guy,” said Dr. Atul Gawande, a surgeon at Brigham and Women’s Hospital who last fall launched a program aimed at finding simple solutions to complex health care problems. Called Ariadne Labs, it is overseeing a study of an end-of-life conversation guide.

Gawande’s sentiment, expressed during a presentation Tuesday, is common among doctors, many of who are poorly trained to have even a 20-minute conversation with a patient about their desires and priorities before death, said Dr. Rachelle Bernacki, a geriatric and end-of-life care specialist at Dana-Farber Cancer Institute and the study’s lead author.


Dr. Susan Block, an oncologist at Dana-Farber and a senior author of the study, said many doctors fear that a conversation about planning for death will trigger extreme emotional responses from patients they “can’t fix.”

But studies have found that early discussions of a patient’s plans and wishes makes them more likely to be able to die at home or in hospice rather than in an intensive care unit. Those conversations can even prolong a patient’s life, research has shown.

To Bernacki, Block, and Gawande, the answer to physicians’ reticence is a checklist.

In the study, clinicians receive a seven-question guide to a conversation with dying patients. Doctors begin by asking patients what their understanding of their illness is. They go on to assess the patient’s fears and worries, for example asking what abilities are so critical that they could not live without them. The doctor might provide examples, such as eating or recognizing family members.

Afterward, patients and doctors are surveyed about their experience. Their responses will be compared with those of patients and doctors not using the conversation guide.


Ariadne Labs, founded last October, is Gawande’s brainchild. A joint venture between Brigham and the Harvard School of Public Health, Ariadne runs its own projects.

The labs take their name from the Greek goddess who led Theseus out of a labyrinth using a simple piece of thread. The metaphor is purposeful: Gawande said modern health care is a complex maze in need of basic solutions.

Gawande pioneered the checklist notion for reducing surgical errors, adopting it from the methods airline pilots, Walmart Stores, and even the crew of the rock band Van Halen use. Applying that to operating rooms, he found, can significantly reduce complications and improve team dynamics. The checklist requires doctors, anesthesiologists, nurses, and anyone else in the room to verbally check in with each other multiple times during the operation.

The core of the idea is “that you can put in simple systems that dramatically change results, simple systems that are more powerful than a drug, more powerful than a new surgical device,” he said.

Gawande’s team applied the checklist concept to childbirth, creating a template for safer deliveries in south India. Before the delivery checklist, doctors there met fewer than 10 of the World Health Organization’s 29 recommended birth safety practices. Afterward, doctors met 25 of the standards.

The surgical checklist required hospitals to rethink long-held elements of operating room culture, said Dr. William Berry of the Harvard School of Public Health, who in another Ariadne project is helping to launch the safe-surgery checklist in South Carolina hospitals.


Most doctors have been raised to prize autonomy, Gawande said, and the checklist forces them to “flatten the hierarchy” of the operating room.

In a global study, a surgical checklist reduced deaths during or immediately after operations from 1.5 percent to 0.8 percent, and lowered postsurgical complications from 11 percent to 7 percent.

Though the end-of-life care project is still in research, its aim is to deliver the same improvement in patient care. Bernacki said the study, which focuses on cancer patients, could become a template for other kinds of illnesses.

Sanjena Sathian can be reached at sanjena.sathian@globe.com. Follow her on Twitter @sasathian.