Conflict resolution at the end of life

Objective: Limited empirical research has examined how decisions are made w hen the preferences of terminally ill patients conflict with physicians' re commendations. This study sought to investigate physicians' strategies for resolving conflicts with dying patients, Design: Cross-sectional, qualitative interviews, Subjects, Subjects were 158 physicians caring for at least one terminally i ll patient. Setting: University medical center. Measurements and Main Results: We analyzed physicians' responses to the ope n-ended interview questions, "How do you handle a situation when a patient wants a treatment that you believe does not provide any benefit?" and "How do you handle a situation when a patient does not want a treatment you thin k would be beneficial?" For patient requests of nonbeneficial treatments, p hysicians reported the following as important: negotiating with and educati ng patients (71%), deferring to patient requests for benign or uncomplicate d treatments (34%), convincing patients to forgo treatments (33%), refusing patient requests for nonbeneficial treatment (22%), using family influence (16%), not offering futile treatments (13%), and referring to other physic ians for disputed care (9%), Potential harm (23%) and cost of treatment (18 %) were reasons cited for withholding treatments, In response to patient re fusals of beneficial treatments, physicians report the following as importa nt: negotiating with patients (59%), convincing patients to receive treatme nt (41%), assessing patient competence (32%), using family influence (27%), and referring to other physicians (21%), Conclusions: Physicians vary in the communication and negotiation strategie s they use when their medical judgment conflicts with dying patients' prefe rences. Medical ethicists could play a greater role in teaching ethically i mportant communication skills. Physicians providing care at the end of life report strategies for respecting patients that reflect graduated degrees o f accommodation tailored to the costliness and riskiness of requests; they are most accepting of patient requests for benign, technically easy, inexpe nsive, and medically effective treatments.