Integrating patients' nonmedical status in end-of-life decision making: Structuring communication through 'conferencing'

This paper considers the nonmedical status of patients in end-of-life decisions. Considering nonmedical factors is not yet routine, particularly in decisions to withhold or withdraw treatment. The paper advocates that nonmedical factors - the capacity and willingness to withstand continuing treatment - are essential to ensure that decisions taken are in the patient's best interest. We argue that including this dimension of patient care not commonly considered gives balance to decisions about continuing treatment where its benefit is diminishing. Drawing on a qualitative study of intensive care nursing in a large public hospital in Sydney, Australia, the paper exemplifies and interprets the tendency of some clinicians to not disclose the medical and nonmedical status to conscious patients, and the environment of mistrust and conflict that can result. We propose a process of 'conferencing' - a regular, inclusive, ongoing, and dynamic process of communication begun early in the patient's admission - to allow multidisciplinary clinicians to manage their differences, agree on patient-care goals, and prepare the patient and their family for the experience of dying. By integrating both medical and nonmedical factors, conferencing becomes the means of enacting and embedding a multidisciplinary, multidimensional approach to end-of-life care.