Making Decisions with Families at the End of Life

Abstract

Because advance directives are not yet the norm, end-of-life decisions for patients without medical decision-making capacity are made regularly within discussions between the patient’s physician and family. Communication and decision making in these situations require a complex integration of relevant conceptual knowledge of ethical implications, the principle of surrogate decision making, and legal considerations; and communication skills that address the highly charged emotional issues under discussion. The most common pitfalls in establishing plans of care for patients who lack decision-making capacity include failure to reach a shared appreciation of the patient’s condition and prognosis; failure to apply the principle of substituted judgment; offering the choice between care and no care, rather than offering the choice between prolonging life and quality of life; too literal an interpretation of an isolated, out-of-context, patient statement made earlier in life; and failure to address the full range of end-of-life decisions from do-not-resuscitate orders to exclusive palliative care. (Copyright© 2004 American Academy of Family Physicians.) SA Fam Pract 2006;48(6): 24-29 Permission from the AAFP was granted to publish this article in the hardcopy only. Kindly refer to www.aafp.org or subscribe to the hardcopy of South African Family Practice.