Letters Section Editor: Stephen J. Lurie,
MD, PhD, Senior Editor.
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.
Prendergast TJ, Puntillo KA. Shared Decision Making About Withdrawing Treatment. JAMA. 2003;289(8):981. doi:10.1001/jama.289.8.981a