Review of The Conversation: A Revolutionary Plan for End-of-Life Care by Angelo Volandes

by Andi Chatburn, DO

As a palliative care physician, The Conversation by Dr. Angelo Volandes is a book I want to see being read, passed along and read again in every coffee shop, book club and doctors’ lounge in my community. Volandes describes his new book The Conversation as a memoir, but in truth it is a “how-to” guide for having tough discussions in the context of serious illness. It is a “quick-start” for ubiquitous primary palliative care. Nothing in this book will be earth-shattering or revolutionary to the Palliative Care physician- it chronicles our every day experience. What makes Volandes’ book revolutionary is the way he makes it accessible to everyone.

Each chapter paints a different, yet familiar patient story: an elderly Italian matriarch with dementia, a professor of literature with brain cancer, a Hispanic gentleman with end stage Heart Failure, a young mother with breast cancer, the author’s own father who suffers a stroke. As Volandes recounts the story of his encounter with each patient, he reveals the unique social context and web of relationships that makes each Conversation different. He shows how there are many different approaches to The Conversation, and that there is no one “right road” but the same destination (77). He goes on to make all of this accessible:

• Describes the complex medical ethics concepts of proportionality, capacity and futility in a way that is easy to comprehend (5).
• Transforms complex heart failure physiology into common, accessible language, describing it “like a runner falling behind on a treadmill, the heart can no longer maintain the pace.” (55)
• Cites up-to-date national guidelines discouraging dialysis in the frail elderly (90).
• References the now classic NEJM article debunking the myth of effective TV CPR (79-80) and makes it accessible to a non-medical reader.

His easy scripting is a model for physicians young and old wanting to practice goals of care conversations asking, “Mrs. Sanchez, how was your husband these last few months? Was he doing the things he enjoyed, things that gave him happiness?” (56) Then shows the progression of The Conversation over several days and as different interventions come into play, including the honest aspects of moral distress created by being a keeper of the patient story when the proverbial “Daughter from California” changes the plan of care (59-60).

The second half of the book is a personal narrative on how Volandes started filming, creating, and studying the effect of the VIDEO Consortium (Video Images of Disease for Ethical Outcomes, see website acpdecisions.org) and his own reactions to his father’s stroke. The videos, which were were made to supplement doctor-patient discussions and to provide information for patients to make truly informed decisions about their care. “When patients have honest exchanges and have the tools necessary to understand their choices at the end of life, then they—not the health care system—remain in charge of decisions about how they want to live.” (137)

Half way through the book (62-63) and again in the four Appendices, Volandes provides a literal script for patients, families and providers to use when starting an uncomfortable conversation about wishes for end of life care. Appendix II provides a how-to guide for completing Advance Directives and Appendix IV is a brief list of online resources, including Ellen Goodman’s Conversation Project and CAPC’s public site getpalliativecare.org. Perhaps I will plant copies of this book in my local gym locker room and leave it on my neighbors’ doorstep.