title: Avoiding iatrogenic harm to patient and family while discussing goals of care near the end of life.
abstract: BACKGROUND
  Treatment of suffering is a core mission of medicine. Communication about treatment planning with the patient and family, called the goals of care discussion, offers the opportunity to provide effective relief. Such communication is particularly important near the end of life, because many medical decisions are determined then by emotional considerations and personal values.
  
  
  OBJECTIVE
  To define common unintended clinician behaviors, which impair discussion about goals of care near the end of life. To discuss the relationship between: (1) the medical decision-making responsibilities of patient and family, (2) clinician communication, (3) iatrogenic suffering, (4) the impact on medical decision-making, and (5) patient and family outcomes.
  
  
  METHODS
  Thematic literature review.
  
  
  RESULTS
  The authors discuss how omission of the integral emotional and social elements of the goals of care discussion are reflected in five unintended clinician behaviors, each of which may impair medical decision-making and unknowingly induce patient and family suffering. We posit that such impaired decision-making and suffering may contribute to demands for ineffective, life-sustaining interventions made by the patient and family or, conversely, to requests for hastened death.
  
  
  CONCLUSIONS
  Understanding the challenges in the discussion about goals of care near the end of life will facilitate the development of more effective approaches to communication and shared decision-making. The authors hypothesize how decreased suffering through improved communication should diminish the occurrence of depression, anxiety disorders, and complicated grief in the patient and survivors, potentially improving medical outcomes. Proposed experiments to test this hypothesis will address important public health goals.
authors.affiliation: Long Island Jewish Medical Center, Departments of Medicine and Psychiatry, New Hyde Park, NY 11040, USA. weiner@lij.edu
authors.forename: Joseph S
authors.initials: JS
authors.lastname: Weiner
authors.forename: Jesse
authors.initials: J
authors.lastname: Roth
mesh_terms: D003142:Communication; D003657:Decision Making; D006801:Humans; D007049:Iatrogenic Disease / Q000517:prevention & control*; D010166:Palliative Care; D011369:Professional-Patient Relations; D013315:Stress, Psychological; D013727:Terminal Care; D014481:United States