Perspectives on Care at the Close of Life Section
Editor: Margaret A. Winker, MD, Deputy Editor, JAMA.
Author Affiliations: Department of Medicine,
University of Washington, Seattle (Dr Back), and Department of Medicine, University
of Pittsburgh, Pittsburgh, Pa (Dr Arnold).
Physicians often assume that conflict is undesirable and destructive,
yet conflict handled well can be productive, and the clarity that results
can lead to clearer decision making and greater family, patient, and clinician
satisfaction. We review the course of Mrs B, an 84-year-old woman with advanced
dementia and an advance directive stating no artificial hydration or nutrition.
Over the course of her illness, her family and physicians had conflicting
opinions about the use of short-term tube feeding and intravenous hydration
in her care. We describe the conflicts that arose between her physicians and
family and a typology of conflicts common in care of patients who are seriously
ill (family vs team, team member vs team member). Drawing from the business,
psychology, and mediation literature, we describe useful communication tools
and common pitfalls. We outline a step-wise approach that physicians can use
to deal with conflicts and the use of treatment trials as a strategy to address
conflicts about the use of life-sustaining medical interventions.
Back AL, Arnold RM. Dealing With Conflict in Caring for the Seriously Ill“It Was Just Out of the Question”. JAMA. 2005;293(11):1374-1381. doi:10.1001/jama.293.11.1374