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Input: Dr. Thalia Krakower (right)  a primary care physician  gets advice from Dr. Juliet Jacobsen  medical director of the Continuum Project at Massachusetts General Hospital in Boston  during a January training session on how to talk to seriously ill patients about their goals and values. (Melissa Bailey/KHN) (Photo: Melissa Bailey  Kaiser Health News)
Dr. Juliet Jacobsen  medical director of the Continuum Project at Massachusetts General Hospital in Boston  trains primary care doctors in how to talk to patients with serious illnesses about their goals and values. (Melissa Bailey/KHN) (Photo: Melissa Bailey  Kaiser Health News)
At Mass General  Dr. Juliet Jacobsen  a palliative care physician  serves as medical director for the Continuum Project  a large-scale effort to quickly train clinicians to have these conversations  document them and share what they learn with one another. The project ramped up in January with the first session in a series that aims to reach 250 primary care providers at the hospital.
At a recent training session   Jacobsen  gave clinicians a laminated page with scripted language to help them along. When the participants role-played with professional actors  difficulties quickly emerged.
"How long should we let them be silent and sad?" Krakower asked  Jacobsen . "We always step in too soon."
Physicians let patients speak an average 18 seconds before interrupting them  research has found.  Jacobsen  encouraged doctors to allow more silence  and to respond to patientsâ emotions  not just to their words.
The scripted conversation is quite different from what doctors have been trained to do   Jacobsen  acknowledged. It doesn't aim to reach any decision  nor to fill out end-of-life paperwork.
In a pilot at Brigham and Women's Hospital in Boston   Jacobsen  noted  the conversations typically lasted 22 to 26 minutes.
At another moment during role-play   Jacobsen  stepped in when a doctor skipped over the section in the script where she was supposed to share prognostic information.
The topic is avoided for many reasons   Jacobsen  later said: Clinicians' schedules are crammed. They may not want to scare families with a timeline that turns out to be wrong. And they may not know what language to use  especially when the disease trajectory is uncertain.
When a doctorâs message moves abruptly from "everything's great" to "she's dying  " Jacobsen  said  patients and their families don't have enough time to adjust to the bad news.
To address that problem   Jacobsen 's team suggests language that helps clinicians discuss a prognosis without asserting certainty: "I worry the decline we have seen is going to continue " or  "I worry something serious may happen in the next few months."

Doctors Learn How To Talk To Patients About Dying