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Dealing with conflict in caring for the dying patient

PITTSBURGH, March 15 How can a dying patient's family members and physicians get along when faced with difficult decisions on end-of-life treatment? The medical and emotional issues surrounding the care of a dying patient are both stressful and complicated, as highlighted in this week's Journal of the American Medical Association Clinician's Corner Perspectives on Care at the Close of Life, which highlights the case of an 84-year-old woman with advanced dementia whose advance directive states that she does not want artificial nutrition or hydration. Over the course of her illness, her family and physicians conflict about the use of a short-term feeding tube and intravenous hydration.

From this case study, authors Robert M. Arnold M.D., Leo H. Criep chair in patient care, professor of medicine, and chief, section of palliative care and medical ethics at the University of Pittsburgh School of Medicine along with Anthony L. Back, M.D., an oncologist and medical ethicist from the University of Washington, Seattle sought ways to identify conflict and make recommendations on how to avoid the pitfalls and recognize disputes by employing useful communication tools.

"Physicians often assume that conflict is a bad thing and something that should be avoided, yet conflict handled well can be productive and the clarity that results can lead to clearer decision making and greater satisfaction," says Dr. Arnold. The five major types of conflict the authors identified include physician-family conflict, physician-nurse conflict, physician-physician conflict, family-family conflict and physician-patient conflict.

In the physician-family conflict scenario, family members may have concerns that hospitals do not respect their roles as caregivers, that they do not get the information they need or that the decisions are inconsistent with their wishes.

In the physician-nurse conflict scenario, previous studies in the intensive care unit suggest th
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