BMJ  2007;334:239-241 (3 February), doi:10.1136/bmj.39048.475046.68

Analysis

Defining limits in care of terminally ill patients

¹ Houston Center for Quality of Care and Utilization Studies, Sections of Geriatrics and Health Services Research, Michael E DeBakey VA Medical Center, 2002 Holcombe Boulevard, Houston, TX 77030, USA, ² North Florida/South Georgia Veterans Health System, Gainesville, FL 32608, USA, ³ Medical University of South Carolina, Department of Biostatistics, Bioinformatics, and Epidemiology, Charleston, SC 29425, USA, ⁴ Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX 77030, USA

Despite what they might say, people at the end of life rarely want everything or nothing. Ursula Braun and colleagues explain how to understand and meet their needs

The first 150 words of the full text of this article appear below.

Invasive procedures in terminally ill patients often fail to change the course of disease.^{1 2} Interventions can become inappropriate overtreatment if they result only in disease related and iatrogenic harm to the patient. Untimely referral to a hospice, poor technical performance, overuse of interventions inconsistent with preferences and prognosis, and poor communication,³ increase the likelihood of inappropriate clinical intervention.

To facilitate appropriate care and avoid inappropriate interventions doctors need to anticipate discordance between their views and those of patients or surrogates, using the informed consent process to prevent potential discordance from becoming actual discordance and responding quickly when conflicts do occur.^{4 5 6} It is imperative for good end of life decision making to identify, explain, and negotiate consensus therapeutic goals to ensure that appropriate treatment occurs. This process requires effective communication skills and cultural sensitivity. The clinical scenario below (which is fictitious but based on experience) illustrates the need for a proactive . . . [Full text of this article]

Clinical scenario

Implementing the doctor's role

A good death

Responding to requests

Build consensus

Document agreements

Planned discharge

Discussion

Resolving conflict

Steps to avoid inappropriate intervention

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