The shared burden: when physicians and families decide to forego life-sustaining treatment

Family physicians are being called upon to make decisions regarding whether to forego life-sustaining treatment. These decisions are made based on consultation with the family of the patient but are complicated by problematic family interactions. The family physician can manage difficult family reactions and assist the family in making a decision by understanding that there are common reactions to loss and bereavement on the part of family members such as anger, denial, and feelings of helplessness; assessing whether problems arise from chronic family conflicts (marital, parent-child, or previous unresolved mourning) or are situation related (unexpressed feelings, how to tell others, need to feel they have done everything, overwhelming other stresses); and incorporating several specific techniques into their practices such as family conferences, accepting anger, involving anxious members in treatment planning, referral to self-help family groups, reframing the decision in terms of the patient's wishes, and negotiating mutually acceptable solutions when patient or family members disagree.