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Doctors vary in how they resolve medical conflicts with dying patients

When dying patients demand or refuse treatments, doctors often feel compelled to comply with the wishes of the patients and their families, even when these demands conflict with the doctor's sense of what treatments constitute high-quality care. Doctors also may feel pressure to limit access to treatments because of concerns about compromising human dignity for minimal benefit or the costs of the treatment (complications, harm, and financial costs). Physicians vary in how they communicate and negotiate with patients to resolve such conflicts, according to a study that was supported in part by the Agency for Healthcare Research and Quality (HS06655).

The researchers interviewed 158 doctors at one medical center who were caring for at least one terminally ill patient about how they would handle such conflicts. Seventy-one percent of doctors said they would negotiate with and educate patients who asked for nonbeneficial treatments, 34 percent would defer to patient requests for benign or uncomplicated treatments, and 33 percent would try to convince patients to forgo nonbeneficial treatments. About one-fifth of doctors (22 percent) would refuse patient requests for nonbeneficial treatment, 16 percent would use family influence, 13 percent would not offer futile treatments, and 9 percent would refer patients to other doctors for disputed care. Twenty-three percent of doctors cited potential harm and 18 percent cited cost of treatment as reasons for withholding nonbeneficial treatments.

In response to patient refusals of beneficial treatments, 59 percent of doctors would negotiate with patients, 41 percent would try to convince patients to receive the treatment, 32 percent would assess patient competence, 27 percent would use family influence, and 21 percent would refer the patient to other physicians.

In conclusion, the authors note that physicians providing care at the end of life respect autonomy through strategies that involve graduated degrees of accommodation. Physicians report being most accepting of patient requests for benign, technically simple, inexpensive, and medically effective treatments. The authors point out that medical ethicists could play a greater role in teaching communication skills to clinicians to help them mediate and resolve ethical conflicts with patients.

See "Conflict resolution at the end of life," by Michael D. Fetters, M.D., M.P.H., M.A., Larry Churchill, Ph.D., and Marion Danis, M.D., in the May 2001 Critical Care Medicine 29(5), pp. 921-925.

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