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This is not a pleasant topic, but since there was some discussion on the list a while back, I thought it was worth posting. Understanding Conflicts Is Key To Aiding End-Of-Life Decision-Making NEW YORK, Feb 16, 2000 (Medical Tribune) - Caring for the terminally ill has always been a difficult time for physicians, patients and the patients' loved ones. Families of patients often feel confused and helpless, which may lead to a questioning of the health care team's intentions. A new report suggests that identifying and understanding the sources of conflicts between doctors and patients' families may help ease the decision-making process. Causes of conflicts may include miscommunication between the doctor and the patient's family, a difference in values and a doctor's underestimation of the patient's quality of life. "By considering this list of potential sources of conflict, clinicians can identify more readily and accurately the causes of difficult interactions with families of terminally ill patients regarding decisions to limit treatment," said the study authors. The study was led by Dr. Susan Goold, assistant professor of internal medicine and associate director for ethics and health policy at the University of Michigan Medical School in Ann Arbor. The report is published in the February 16 issue of the Journal of the American Medical Association (www.jama.com). "Almost all physicians have to deal with something like this at some point in their career, but not necessarily often enough to make them good at it," Goold said. "This is a way of hopefully getting the message out to practicing physicians." Goold and her co-authors used the term "differential diagnosis" to describe their suggested approach to these situations. Differential diagnosis is a term familiar to many doctors. This type of diagnosis involves determining which disease a patient is suffering from by systematically comparing clinical findings and symptoms to a list of possible diseases. In the paper, the authors suggested applying differential diagnosis to end-of-life decision-making. In this case, the conflict can be seen as "symptoms," while the possible characteristics of both the physician and the patient's family are possible "diseases." By examining these "symptoms" and comparing them to the "diseases," physicians may better understand the problems and how to work through them. "Talking about death is hard for doctors as well as families," Goold remarked. She teaches a class in end-of-life decision-making for residents and medical school students. "Most doctors are trying to do the right thing in these situations," Goold added. "They're just not always sure what the right thing is." Conflict and stress are very common when physicians and families are met with the decision of limiting care for terminally ill patients. "These kinds of situations are not necessarily preventable," Goold said. "When someone is in the hospital dying, a lot of emotions come out, a lot of baggage comes out, and you shouldn't necessarily expect things to go smoothly." Goold recommended that families talk about what to do before this situation actually happens. "A family member making a decision for a patient who knows that they're doing what the patient would want doesn't have nearly as much guilt involved in making that decision," she explained. She also added that the health care team sees family members who actually know what the patient wants as more credible decision-makers. "Try to keep the lines of communication open within the family and between the family and the health care team," Goold stressed. "Don't let the relationships break down." Journal of the American Medical Association (2000;283:909-914) ©1999 InteliHealth, Inc. All rights reserved. All information is intended for your general knowledge... -- Judith Richards, London, Ontario, Canada [log in to unmask]