title: Resolving conflicts surrounding end-of-life care.
abstract: Critical care physicians are frequently called on to negotiate issues of medical management with patients, their families, and other physicians. These decisions frequently revolve around end-of-life care. Recent data suggest that such discussions are manageable. In one study, 57% of patients and surrogates agreed immediately to a physician's recommendation to limit intensive care and 90% agreed within 5 days, while multiple treating physicians came to consensus about such limits within 4 days in 92% of cases. If conflicts are rare, they are strongly felt. They arise when any one of the parties to a decision insists on continued care against the considered judgment of another. Since the alternative to aggressive ICU care is usually the death of the patient, it seems difficult to reconcile a physician's refusal to treat with patient autonomy. The concept of a fiduciary offers a model of the physician-patient relationship in which the physician commits himself to the patient's best interests but retains a role in defining those interests. This model offers significant benefits over medical futility in negotiating conflicts over end-of-life care.
authors.affiliation: Dartmouth Medical School, Hanover, NH, USA.
authors.forename: T J
authors.initials: TJ
authors.lastname: Prendergast
mesh_terms: D003220:Conflict, Psychological; D003422:Critical Care; D003659:Decision Making, Organizational; D004992:Ethics, Medical; D005190:Family / Q000523:psychology*; D005260:Female; D006801:Humans; D008297:Male; D018447:Medical Futility; D008875:Middle Aged; D017008:Negotiating; D010819:Physician's Role; D010817:Physician-Patient Relations; D013727:Terminal Care