Our patients

First, most patients who are approaching the end are looking for an opportunity to talk about what the future might hold for them. Our in-depth qualitative research has shown that nearly everyone with a life-threatening progressive illness has two narratives competing in their mind: the public restitution narrative of ‘I am just fine’, and the more private realistic narrative that they will die one day (Murray et al., Reference Murray, Boyd, Kendall, Worth, Benton and Clausen2002). Most people know they will die, and would like a chance to talk with someone they can trust, someone who has walked with death before. Therefore, if patients say they are ‘just fine’, and you feel that they are at risk of dying in the near future, why not gently ask them: ‘But are there ever days when you do not feel so fine?’, and wait and listen.

Moreover, we have found out in the United Kingdom that, where planning for the future has been raised by GPs and the patient is placed on the practice supportive and palliative care register, most of this group dies at home. Whereas those not on the register more frequently have unplanned deaths in hospital (Harrison et al., Reference Harrison, Cavers, Campbell and Murray2012). As it is recognised that most people would actually prefer to die at home, helping them discuss their own immortality might allow them greater choice in not only where they died but also in other aspects. Patients are often waiting for the doctor to raise the issue of dying, but like an elephant in the room, it is raised neither by the GP nor the patient nor the family carer, and thus we must take time to actively listen (Boyd et al., Reference Boyd, Mason, Kendall, Barclay, Chinn, Thomas, Sheikh and Murray2010).

Family carers

Second, talking with relatives and informal carers of patients about the future is greatly appreciated by them. Such people are rarely acknowledged as providing as much practical care as they do, and are the main coordinators of care for our most ill patients, where they are available. Even when a patient is admitted to a care home, relatives greatly appreciate being involved in planning for their stay in the home, their Resuscitation Status should they collapse and their death in due course. Indeed, advance care planning routinely done on admission to a care home, together with the relative, can be really effective in improving care and carer satisfaction (Watson et al., Reference Watson, Hockley and Dewar2006).

Doctors and nurses

Third, talking more openly about death as a clinician allows a deeper relationship with patients. An open awareness about what might happen tends to create a more comfortable and easier platform to help people. If a diagnosis that someone may well die is made, the patient and doctor then can together face up to that and optimise the patients’ health so that they can live as well as possible and then die well. ‘Health promoting palliative care’ is a new concept that calls for ‘Living to the full and then dying well’. It can be very satisfying for the clinician to be able to focus positively on helping the patient optimise their quality of life before the best death possible for them. We cannot prevent dying but we can face up to it and prevent needless distress and minimise suffering (Kellehear, Reference Kellehear1999).

The NHS

Fourth, talking about dying can also save the NHS many millions of pounds worth of futile treatment, and prevent numerous complaints and iatrogenic risks. Overzealous treatment frequently occurs in each of the three trajectories of physical decline (Murray et al., Reference Murray, Kendall, Boyd, Highet and Sheikh2010). In cancer care, palliative chemotherapy is still common in the last week of life, and response rates for many conditions remain borderline. Similarly, in the organ failure trajectory, patients with heart failure and chronic obstructive pulmonary disease are frequently admitted out of hours, as they are anxious about their breathlessness, when a reassuring visit by a clinician they know and trust might obviate the need for admission. For those dwindling at the end of life in the frailty trajectory or with dementia, advance care planning can decrease admissions from care homes by up to 50%, and avoid many inappropriate hospital admissions (Hockley et al., Reference Hockley, Watson, Oxenham and Murray2010). We need to eliminate the iatrogenic needless suffering fuelled by our denial of death (Enkin et al., Reference Enkin, Jadad and Smith2011).

Society in general

Finally, if there were more discussions about death and dying in the community generally, in our clubs, pubs and even schools, patients and doctors would find it easier to raise it in consultations. We as doctors can help promote a public discourse about death and dying by supporting campaign groups such as ‘Good Life, Good Death, Good Grief’ (http://www.goodlifedeathgrief.org.uk/) in Scotland and ‘Dying matters’ (http://www.dyingmatters.org/) in England. These coalitions produce helpful resources to provoke public discussions, and to bring death back as a character that is sometimes introduced, when appropriate, in conversation. If people talk more about death and dying before they are ill, they will find it easier to raise their mortality later. Moreover, as Iona Heath has written, ‘if we avert our eyes from death we also erode the delight of living, the less we sense death the less we live’ (Heath, Reference Heath2008).