Resolving disagreement during end of life care in the critical care unit: The case for communication not arbitration

Clinical medicine tries to resolve the uncertainties of diagnosis and prognosis. The natural history of the illness is repeatedly examined using both our own knowledge base and that of our colleagues. This is an iterative hypothesis testing process that starts with the history and physical examination and progresses with increasingly complex tests. Thus, the uncertainty of diagnosis and prognosis is diminished but never absolutely eliminated because of the limits of both our knowledge and our tests. Our scientific hypothesis testing, using the reductionist process, by which the whole can be deduced from the sum of its parts, has some human limitations. Science deals with generalities that strive to be objective and value free. In contradistinction, the patient is a unique individual, with deeply embedded personal values, whose wholeness is greater than the sum of his/her parts. For example, the patient may have qualities with descriptors such as insightful, tender, suffering or anxious. Thus, there is often a tension between medicine and science as well as a tension between the wishes of the patient, or Substitute Decision Maker (SDMs), and those of the health care team.