So in case of conflict the clinician feels that the hospital administration will of necessity support patients and families. In the matter of family dynamics, the family's lack of sophistication in working the care system and their inability to understand medical diagnosis and prognosis present great difficulties in acute care settings. Often caregivers are asked by family not to talk to patients. In addition, subplots surrounding family finances, as well as dysfunctional relationships, make direct and simple discussion about EOL issues very difficult. One of the primary challenges faced by all acute care clinicians is to determine the appropriate time for starting EOL discussions.
Prognostic uncertainty is one of the most important issues.
At one time EOL discussions were initiated only when a patient was terminal. This approach urges us to start EOL discussions early to get people used to talking about these issues. As a result, when the time comes for them to make their decisions, they have had some preparation and are more comfortable. Finally, the Toronto study notes, both cultural differences and value differences between caregivers and patients create real barriers. In my institution, several people feel they have responsibility for EOL discussions.