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February 26, 2003

Shared Decision Making About Withdrawing Treatment

Author Affiliations

Letters Section Editor: Stephen J. Lurie, MD, PhD, Senior Editor.

JAMA. 2003;289(8):981. doi:10.1001/jama.289.8.981a

In Reply: Dr Workman identifies a common sticking point for many clinicians who engage in discussions to limit life support. Clinicians and surrogates both have appropriate roles and share responsibility for medical decisions. In Workman's words, if their opinions differ, then "exactly how [is] such sharing . . . to be accomplished"?

We make 3 points. First, our intent was to point out a common flaw in clinicians' communications that has serious consequences, namely, the tendency to see "shared" decision making as an either/or rather than as a both/and phenomenon. We prefer to frame the interaction between surrogates and clinicians as a negotiation rather than one in which parties compete to determine a decision.1 A competitive framework makes the false presumption that one party to the discussion must have ultimate authority. We are not naïve about instances where the relationship between parties breaks down, even if such cases represent a small minority of withdrawal discussions.2,3 However, since both parties have legitimate claims to a decision-making role, whose opinion prevails is not established in advance. "Ultimate" authority to determine a decision is given by society to the courts.

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