Working toward consensus: Providers' strategies to shift patients from curative to palliative treatment choices

End-of-life decision making is a complex phenomenon and Providers, patients , and families often have different views about the appropriateness of trea tment choices. The results Presented here are part of a larger grounded-the ory study of reconciling decisions near the end of life. In particular, we examined how Providers (N=15) worked near the end of Patients' lives toward changing the treatment decisions of patients and families from those decis ions that Providers described as unrealistic (i.e., curative) to those that Providers described as more realistic (i.e., Palliative). According to Pro viders, shifting Patients' and families' choices from curative to Palliativ e was usually accomplished by changing patients' and families' understandin g of the Patient's overall "big picture" to one that was consistent with th e providers' understanding. Until patients and families shifted their under standing of the patient's condition-the big picture-they continued to make what providers judged as unrealistic treatment choices based on an inaccura te understanding of what was really going on. These unrealistic choices oft en precluded possibilities for a "good death." According to providers, the purpose of attempting to shift the patient or proxy's goals was that realis tic goals lead to realistic Palliative treatment choices that providers ass ociated with a good death. In this article we review strategies used by pro viders when they believed a Patient's death was imminent to attempt to shif t patients' and families' understandings of the big picture, thus ultimatel y shifting their treatment decisions. (C) 2001 John Wiley & Sons, Inc.