[Talking about unspeakable: insights from patient-centered medicine to palliative paternalism.]

The literature highlights the importance of involving the patient as a partner of care, using a patient-centered approach aimed at improving a process of share decision-making. However, there are clinical situations in which a shared decision-making process is difficult and its actual achievement is even more complex, as in the case of end-of-life decisions, in which a decision about death is a tremendous weight for both patients and their caregivers. In such situations, we wonder what kind of position physicians should assume in order to be patient-centered but also to reduce the patient suffering. Our proposal is to assume the perspective of palliative paternalism: doctors should provide a communication approach that determines the appropriate level of patient/parent autonomy in the process of decision making. In other words, doctors are required to share the information with patients, according to their desires, possibilities and resources, and to facilitate a share-decision making process. However, when the time of the decision comes, physicians should take full responsibility for giving voice to the patient's choices, putting them in action in his/her end of life and raising patients and their caregivers from the burden linked to the actual implementation of the decision.