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December 22 2010

Shared and Physician-Directed Decision Making in Clinical Practice—Reply

JAMA. 2010;304(24):2697-2698. doi:10.1001/jama.2010.1788-a

In Reply: Dr Berger raises several important and well-considered points. When physicians follow well-accepted clinical practice guidelines and present only those options that are widely considered to be medically indicated (not presenting other nonmedically–indicated interventions), this is consistent with appropriate physician-directed medical decision making.

Berger further raises the issue of end-of-life decision making and notes that there may be times when physicians ought not to offer interventions that are highly burdensome and will not alter prognosis. Physicians must be careful, however, to differentiate between interventions that will not alter prognosis and interventions that do not further the goals of treatment. There may be times when the goal of treatment is not to survive to discharge but rather to survive long enough to say goodbye to loved ones or to survive long enough to allow family members to visit and pay their last respects before the patient dies. If the patient (or the patient's representative) and physician agree that such goals are appropriate and achievable, there may be times when interventions that will prolong the patient's life for a few days are indicated even when such interventions do not alter the terminal prognosis. Physicians must be careful to ensure that they do not assume that the goal of treatment is always cure.