What is your approach to counseling severely frail older adults regarding their planning for invasive life-sustaining therapy?

My approach is pragmatic, evidence-based, and bi-directional. Patients/family make the decision, but I ensure they are fully informed about the pros and cons and provide them time to think through.

I have three tips: the first is to have a direct, honest, and clear discussion with the patient, who has definitely thought about death already. I avoid euphemisms and say "when you die, or are dying, meaning your heart and lungs stop working." Sometimes I have to press a little for someone who doesn't want to face facts, and this may be uncomfortable for all, but begin with compassion: "I'm worried you'll be greatly harmed if we don't change your care plan." And it can help to get permission: "Are you someone who doesn't want to look at the whole picture, or can I be completely honest with you about what's going on?" Almost everyone opts for facing reality; those who don't -> you need a different decision maker anyway.

Second, I would reco...