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.