When patients & families request that "everything" be done

• Understand what "everything" means
  • "Every treatment with even the slightest possibility of benefit" (rare)
  • "Everything that you, as my physician, feel is worthwhile"
  • "Everything to relieve symptoms, even though it may shorten life"
• Communicate prognosis
  • Use clear & direct language ("Your mother is dying")
  • Maintain consistent messaging
  • Avoid discussing minutiae of management
• Propose a philosophy of treatment
  • Offer medical recommendations with appropriate limits to therapy
  • Discuss what will be done before covering what will not be done
  • Illustrate how the recommendations support the patient's values
• Support emotional response
  • Validate emotions & invite conversation ("What is the toughest part of this for you?")
  • Reaffirm commitment to caring for the patient no matter what happens
• Negotiate disagreements
  • Review understanding & seek common ground
  • Seek external input for persistent, unresolved conflict (eg, from ethics committee)