How your patient's ‘bucket list’ can help guide care

Inquiring about patients' bucket lists may seem a bit forward, but one researcher believes that learning about future goals can help guide care and strengthen the physician-patient relationship.

A bucket list doesn't necessarily suggest “kicking the bucket.” While it can be a list of unaccomplished tasks a person wants to complete before dying, it can also be any number of experiences one wants to have during his or her lifetime, explained internist Vyjeyanthi S. Periyakoil, MD, who is also a geriatrics and palliative care doctor.

In an online survey of 3,056 U.S. participants, she and her coauthors found that bucket lists were quite common: 91.2% of participants reported that they had one, according to results published online in February 2018 by the Journal of Palliative Medicine. Those who said faith, religion, and/or spirituality were important to them were most likely to have a bucket list, compared to those who found the concepts unimportant.

In a random sample of 40 bucket lists, researchers identified six major themes and then validated these themes in the other 3,016 participants: desire to travel (78.5%), desire to accomplish a personal goal (78.3%), desire to achieve specific life milestones (51%), desire to spend quality time with friends and family (16.7%), desire to achieve financial stability (24.3%), and desire to do a daring activity (15%).

Dr. Periyakoil, lead author of the study and associate professor of medicine (primary care and population health) at Stanford University School of Medicine in California, recently spoke to ACP Internist about why internists should ask about their patients' bucket lists.

Q: Why did you decide to do this study?

A: Sometimes, what I found happening in my own practice was that my patients had important life events that I would find out about after the fact. The patient would be in my office, and then in casual conversation, they would be like, “Yeah, I feel bad that I had to miss my grandson's wedding,” and I'd say, “What? When was that?” and the patient responded, “It was last week, but my angiogram was scheduled the day before the wedding. I lost a lot of blood during the procedure and did not feel too good—was too dizzy and had to miss the wedding.” … A lot of times, just us knowing about what the patient wants to do in the upcoming year will help us manage their treatments and procedures to make sure they do not miss out on important life events. I want to make sure that my treatments don't get in the way of their life to the extent possible, or if that is at risk of happening, I want the patient to know about [any] possible impact on their life and make informed decisions. … That's the broad context of why I have always [asked about bucket lists] in my clinical practice, and then I decided to study whether this was an issue that patients could relate to.

Q: How did you start to do this in practice?

A: Ever since I was a fellow here at Stanford, it was something really casual where I would ask, “So, what's on your list this year?” It's not that it's “the bucket list” and you should check it off before you die. That's one extreme version of this for patients who are seriously ill in the last year or two of life. But I feel that it is just as relevant to any adult who is getting care in your office, and it really takes a minute or two just basically asking, “So what are your plans for this year? Are you working on some projects? Any big events? Any travel plans?”

Q: How does talking about bucket lists affect the clinical care plan?

A: In the palliative care realm … I had a patient, a gentleman with colon cancer, who really wanted to get to a point in his illness where he felt a little better and could travel back home to Virginia for an extended family reunion which happens every August. He told me the previous fall he wanted to be able to go. Our goal in his treatment was to make sure that he was comfortable enough to go to that family reunion, which he did, and we wanted to make sure in coordinating with oncology and his surgeon that he wasn't going to be in postsurgical care or getting chemotherapy at that time, where he would be nauseous and feeling unwell for travel.

In the realm of internal medicine, I've had many patients who have very clear life goals. It would be things like “I want to make sure that my family is well taken care of. I am in my 50s and I have two young sons, my wife doesn't work, and my sons are still in middle school, and it's important for me to be healthy until everyone is settled.” That's a very important goal, that's what we want you to do, but you smoking and drinking is not going to get you there. … It's not about getting people to think about their death; it's more about personalizing the care within the context of their life so we are doing everything we possibly can to help them to live longer, live better, and have agency in their own care.

Q: Do you recommend asking all patients about this?

A: I change the language based on my patient's health and anticipated lifespan. … We should always be personalizing care for every single patient, and depending on what their anticipated lifespan is and what chronic illness they have or may not have, that would change the flavor of the conversation. If this was a person with metastatic lung cancer and I think they have a year to live, that conversation is going to be qualitatively different, but the overall framework is the same: “What do I need to know about what matters to you so that I can provide care that enhances your life and doesn't get in the way of it?”

Q: Does the conversation take a lot of time?

A: No, it usually doesn't because you're asking this in passing. The way I practice, I have almost like a Rolodex in my head where I know for each patient some key thing about them that they care deeply about, and I use that as an entry point into the conversation to personalize it. And I will usually put a notation in my chart. For example, I had a patient who was a jazz musician and deeply involved in organizing a jazz festival here and has done that for 20-some years. I know that about him, so I'll say, “How's the music coming along?” That's it. I am by no means advocating that each physician should have a half-hour conversation with each patient about their bucket list because that's just not feasible …. All I'm saying is, personalize the care, spend five seconds to know something important to your patient, and build on that thread over time. And when you pick something that is relevant to their health, then your ability to prevail on lifestyle behaviors is much higher. To my jazz musician, I might say, “If you quit smoking, the nerves in your fingertips will work better and you can play your guitar longer.”

Q: What are your tips for talking with patients about bucket lists in a tactful way?

A: How do you approach these sensitive, nuanced topics in a way that patients feel that you're watching out for their welfare? That's the question. What I would really not want is a well-meaning [doctor] walking into the patient's room and saying bluntly, “Do you have a bucket list? Better start checking off some items off your list, as your time is short.” That would be a terrible disservice to the patient. Instead, think about all the people who provide service to you in your life: your hairdresser, your barber, your manicurist, pedicurist. … While they are providing their care to you, they also manage to engage you in ways that personalize the service they provide. Shouldn't doctors be doing the same thing, but in the context of life and death?