AMA Journal of Ethics

Consideration of what constitutes sufficient information about how donation protocols can interfere with a patient’s dying process is a key feature of consent processes.

Eliciting the patient’s motives and goals and helping the patient and her loved ones explore alternatives are essential to maintaining trusting relationships and open communication.

Interdisciplinary support, securing reliable information from a patient’s health record, and taking a “who, what, when, where, and how” approach to conversation can improve care planning with dying patients and their loved ones.

Barriers to effective prognosis conversations include knowledge deficits, misconceptions, cultural differences, and lack of motivation. These can be addressed head-on by good communication interventions.

A hand signing a do-not-resuscitate order is depicted in the foreground of this image of an elder patient surrounded by closed doors and caving walls.

End-of-life conversations can be delayed by some physicians’ emotional investment in their patients, as in this case of patient with new onset refractory status epilepticus.

Clinical momentum—increasingly aggressive treatment in intensive care settings that can violate a patient’s wishes—is charged by ritually intensifying efforts to “save” a patient, reimbursement patterns that privilege acute interventions, and technology-driven health care.

Physicians new to a case might object to an established care plan. Practice variation, clinical momentum, and how value is assigned by different parties to acute care and comfort measures can each contribute to conflict in these cases.

The AMA Code of Medical Ethics offers guidance on advance care planning, including advance directives, do-not-resuscitate orders, and symptom management.

Countering overmedicalization of death requires acknowledging that dying patients are living patients. It also requires persistent focus on health and wholeness, especially at the end of life, and a solid interdisciplinary approach to supporting dying patients.