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Building trust aids decision making in end-of-life care

From the August ACP Hospitalist, copyright © 2007 by the American College of Physicians.

By Deborah Gesensway

The patient is dying. More medical intervention is futile. But the family, speaking for their loved one, still wants everything done.

Sidebar: Reaching consensus: Tips to avoid conflict in end-of-life care

It's a difficult scenario for many physicians, but there are strategies for coping with it, said Charles E. Schwartz, MD, associate professor of medicine, family medicine and psychiatry at New York's Montefiore Medical Center/Albert Einstein College of Medicine. The key is becoming less judgmental, said Dr. Schwarz, who spoke at the Society of General Internal Medicine's annual meeting in Toronto in May. "We can't prognosticate well, and if the patient is terminally ill, it may not always matter what we do. Maybe we shouldn't fight about it so much."

Because conflicts over futility can create mistrust between families and the health care system, the most important thing a doctor can do is work to build trust, remembering that this is a process that doesn't always happen immediately, Dr. Schwartz advised.

"First, try to understand their point of view," he said. Then continue to meet with the family, pay attention and tell them the truth.

One strategy to "unstick the decision-making process," he said, is to suggest conducting a short therapeutic trial of aggressive treatment. Such a trial could involve continued ventilatory support, antibiotics and/or pressors for a set period of time with concrete criteria for patient improvement. At the end of the defined time period, Dr. Schwartz said, the family and physician should sit down together to discuss results and plan what should—or should not—happen next. For example, the family could decide to begin to withdraw ineffective, burdensome interventions while adding palliative interventions, such as more aggressive pain management and pastoral care.

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Charles E. Schwartz, MD

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Another strategy that can help resolve conflicts, Dr. Schwartz said, is to "shift the burden of responsibility" for very difficult and painful decision-making from the family back to the patient and the physician. Physicians can reframe the family's role by saying things like "I can see how hard this is for you, how hard you are trying to do the right things for [the patient], but you are taking on more than you should," Dr. Schwartz said. He urged physicians to spend time talking with family members to help clarify the patient's goals and wishes and to emphasize that these views, rather than those of the family, should determine medical care.

Moreover, he said, "we as physicians need to shoulder more of the burden" by formulating a care plan that follows the patient's goals and wishes, then giving families "a chance to strenuously object," not the other way around.

In addition, Dr. Schwartz reminded physicians that they should make sure that all dying patients receive palliative care, regardless of whether they are getting aggressive curative care or not.

In the end, Dr. Schwartz said, physicians should remember that coming to grips with death is "a process over time," pointing out that the same tools physicians use to move smokers from a "precontemplation stage" to a stage where they can contemplate quitting can be brought to bear in these cases. "Don't expect change overnight."

Deborah Gesensway is a freelance health care writer in Toronto.

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Reaching consensus: Tips to avoid conflict in end-of-life care

• Withhold judgment

• Build trust

• Pay attention to the family's point of view

• Conduct a collaborative therapeutic trial

• Shift the burden of decisions away from the family to the patient and physician

• Take the initiative and develop a care plan

• Allow families to object

• Always provide palliative care

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated