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End-of-Life Care Can Bring on Challenges for Hospitalists


How do you cope with a family that wants you to "do everything" for their seriously ill loved one? This dilemma was one of the topics explored at the Management of the Hospitalized Patient conference held last month at the University of California at San Francisco (UCSF).

"We don't actually know what 'everything' means to the family, not without probing into a range of possible meanings," said presenter Steve Pantilat, MD, FACP, SFHM, hospitalist and director of the palliative-care service at UCSF Medical Center. "The family may not have a clear understanding of what 'everything' entails, including mechanical ventilation or cardio-pulmonary resuscitation. I prefer to ask, 'How were you hoping we could help?' The answer can provide a great deal of insight."

In spite of various tools to aid decisions, prognosis is inherently uncertain, said co-presenter Matthew Gonzales, MD, assistant professor of hospital medicine and palliative care at UCSF Medical Center. "We use the Palliative Performance Scale [PDF]."

The family might not trust the hospitalist’s prognosis, especially when meeting the doctor for the first time in a stressful situation, and there might be disagreements within the family about the course of treatment, Dr. Gonzales said. Cultural differences also come into play.

"I have started to ask, 'How do you decide these questions in your family?' because of the differences within a cultural group," Dr. Pantilat said. "If they talk about hoping for a miracle, I probe the meaning of 'miracle' to them. Physicians can't work on the basis of miracles; they have to practice medicine. And you should resist getting drawn into a religious debate. That's a loser for the physician."

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