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.
Design: 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.
