In recent years, it has become possible for the end of life to be a negotiated event, particularly in the intensive care unit. A multitude of often unidentified and poorly understood factors affect such negotiations. These include, family dynamics, ever-changing health care teams, inconsistent opinions about prognosis, and cultural differences between physicians, and patients and their families. When these factors converge, conflict may erupt. This article explores the nature, antecedents, and cost of such conflict. Arguments for the importance of balanced communication, negotiation, and mediation in end-of-life care are put forward.
Get full access to this article
View all access options for this article.
References
1.
SingerP.A., BakerG.Hospital policy on appropriate use of life-sustaining treatment critical care medicine. In press.
2.
GambleE.R., McDonaldP.J., LichsteinP.R.Knowledge, attitudes and behavior of elderly persons regarding living wills. Arch Intern Med1991; 151: 277–280.
3.
JoosS.K., ReulerJ.B., PowellJ.L., HickamD.H.Outpatients’ attitudes and understanding regarding living wills. J Gen Intern Med1993; 8: 259–263.
4.
PfeiferM.P., SidorovJ.E., SmithA.C., BoeroJ.F., EvansA.T., SettleM.B.The discussion of end-of-life medical care by primary care patients and their physicians: a multicenter study using structured qualitative interviews. J Gen Intern Med1994; 9: 82–88.
5.
MolloyD.W., GuyattG., ElemayheuE., McllroyW.E.Treatment preferences, attitudes toward advance directives and concerns about health care. Humane Med1991; 7: 285–290.
6.
SamM., SingerP.A.Canadian outpatients and advance directives: poor knowledge, little experience, but positive attitudes. CMAJ1993; 148: 1497–1502.
7.
KeinerM.J., BourgeaultI.L.Patient control over dying: responses of health care professionals. Soc Sci Med1993; 36: 757–765.
8.
DublerN.N., MarcusU.Mediating Bioethical Disputes: a Practical Guide.New York: United Hospital Fund of New York, 1994.
9.
ChristakisN.A., AschD.A.Physician characteristics associated with decisions to withdraw life support. Am J Public Health.1995; 85: 367–372.
10.
WoolleyN.Crisis theory: a paradigm of effective intervention with families of critically ill people. J Adv Nurs1990; 15: 1402–1408.
11.
MillerR.B.Mediation for challenging patients — a promising approach. (editorial) Adv Ren Replace Ther1997; 4: 372–376.
12.
AguileraD.C., MessickJ.M.Crisis Intervention: Theory and Methodology. 5th ed. Toronto: The C.V. Mosby Company, 1986.
13.
RamseyC.N.Family Systems in Medicine.New York: The Guilford Press, 1989.
14.
BowenM.Family Therapy in Clinical Practice.Northvale, N.J.: Jason Aronson, 1985.
15.
RollandJ.S.Family illness paradigms: evolution and significance. Family Systems Med1987; 5: 482–503.
16.
RandoT.A.Loss and Anticipatory Grief.Toronto: Lexington Books, 1986.
17.
RosenE.J.Families Facing Death: Family Dynamics of Terminal Illness.Toronto: Lexington Books, 1990.
18.
ReissD.The Family's Construction of Reality.Cambridge: Harvard University Press, 1981.
19.
KellyS.E.Understanding the practice of ethics consultation: results of an ethnographic multi-site study. J Clin Ethics1997: 8(2): 135–149.
20.
LevineC., ZuckermanC.The trouble with families: toward an ethic of accommodation. Ann Intern Med1999; 130: 148–152.
21.
SchneidermanL.J., JeckerN.S., JonsenA.R.Medical futility: its meaning and ethical implications. Ann Intern Med1990; 122: 949–954.
22.
SchneidermanL.J., JeckerN.S., JonsenA.R.Medical futility: response to critics. Ann Intern Med1996; 125: 669–674.
23.
HalevyA., BrodyB.A.A multi-institution collaborative policy on medical futility. JAMA1996; 276: 571–574.
24.
WeijerC.E., SingerP.A., WorkmanS.R., DickensB.M.Bioethics for clinicians 16. Dealing with demands for “inappropriate” treatment: medical futility and other approaches. CMAJ1998; 159: 817–821.
25.
BowmanK.W.Bioethics and cultural pluralism. Humane Health Care International1997; 13(2).
26.
HarwoodA.Ethnicity and Medical Care.Cambridge: Harvard University Press, 1981.
27.
KleinmmanA.M.Biomedical practice and anthropological theory, frameworks and directions. Annual Review of Anthropology1983; 12: 303–305.
28.
RotterJ.C.Locus of Control: Current trends in theory and research. 2nd ed.New York: Wiley Press, 1996.
HoffmanD.E.Mediating life and death decisions. Arizona Law Review1994; 36(1): 821–877.
31.
BrownF.H.The Impact of Death and Serious Illness on the Family Life Cycle. The Changing Family Life Cycle: a Framework for Family Therapy. 2nd ed. Toronto: Allyn and Bacon, 1990.
32.
BroomC.Conflict Resolution Strategies: when ethical dilemmas evolve into conflict. Dimensions Crit Care Nurs1991; 10: 354–363.
33.
RodningC.B.Coping with ambiguity and uncertainty in patient-physician relationships: 111. Negotiation. J Med Humanities1992; 13: 211–222.
BushR.A.B., FolgerJ.P.The Promise of Mediation: Responding to Conflict Through Empowerment and Recognition.San Francisco: Jossey-Bass Publishers, 1994.
36.
CraigY.J.Patient decision-making: medical ethics and mediation. J Med Ethics1996; 22: 164–167.
37.
PrendergastT.J.Resolving conflicts surrounding end-of-life care. New Horizons1997; 5(1): 62–71.
38.
MillarB.Critical support in critical care. Nursing Times1989; 85(16): 31–33.
