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Discussing Treatment Preferences With Patients Who Want “Everything”

Timothy E. Quill, MD; Robert Arnold, MD; and Anthony L. Back, MD
[+] Article, Author, and Disclosure Information

From University of Rochester Medical Center, Rochester, New York; University of Pittsburgh, Pittsburgh, Pennsylvania; and University of Washington, Fred Hutchinson Cancer Research Center, Seattle, Washington.

Potential Financial Conflicts of Interest: None disclosed.

Corresponding Author: Timothy E. Quill, MD, Center for Ethics, Humanities and Palliative Care, Box 687, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642; e-mail, timothy_quill@urmc.rochester.edu.

Current Author Addresses: Dr. Quill: Center for Ethics, Humanities and Palliative Care, Box 687, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642.

Dr. Arnold: Section of Palliative Care and Medical Ethics, University of Pittsburgh Medical Center Montefiore Hospital, Suite 932W, 200 Lothrup Street, Pittsburgh, PA 15213.

Dr. Back: Seattle Cancer Care Alliance, 825 Eastlake Avenue East, Seattle, WA 98109-1023.

Ann Intern Med. 2009;151(5):345-349. doi:10.7326/0003-4819-151-5-200909010-00010
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When asked about setting limits on medical treatment in the face of severe illness, patients and their families often respond that they want “everything.” Clinicians should not take this request at face value, but should instead use it as the basis for a broader discussion about what “doing everything” means to the patient. The discussion might include questions about what balances of treatment burden and benefit the patient can tolerate and about emotional, cognitive, spiritual, and family factors that underlie the request. After this initial exploration, the clinician can propose a philosophy of treatment and make recommendations that capture the patient's values and preferences in light of the medical condition. Clinicians should respond to emotional reactions, directly negotiate disagreements, and use harm-reduction strategies for the relatively infrequent instances in which patients continue to request burdensome therapy that is unlikely to help. By using this approach, patients, families, and clinicians will be better able to understand each other and join together to develop a treatment approach that best respects patient and family values in light of what is medically achievable.





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Patients should not be asked to 'set limits'
Posted on September 18, 2009
Stephen R Workman
QEII HSC Halifax Nova Scotia
Conflict of Interest: None Declared

"When asked about setting limits on medical treatment in the face of severe illness, patients and their families often respond that they want "everything."

I do not agree with the authors underlying presumption that physicians should ask patients or their family members to "˜set limits.' Setting limits is a burden for physicians because determining whether or not treatments could or could not be effective is an essential aspect of medical practice. (For physicians to knowingly offer ineffective treatments is both dishonest and dishonorable).

Patients should not be asked to set limits"”instead they should be given legitimate choices. For any particular decision it is the task of the physician, not to help the patient make the "˜right decision' or to help them accept treatment limitation, but to ensure that any decision the patient reaches is based upon an accurate understanding of the benefits and harms of the treatments that are offered, and consistent with the patients' beliefs and values. During any such decision making process emotional support is absolutely essential. Decisions reached via this process must be treated with great respect, consistent both with the sanctity of life and the ultimate inevitability of death.

Asking patients to limit treatments, as opposed to choose for or against them, mixes the obligation of physicians to limit treatments with patients' right to choose. The resulting decision making process denigrates both physician expertise and patient preferences.

Finally, in all situations in which death is the likely outcome irrespective of treatments, (CPR for example has a 15% survival rate in all patients) this fact should be established and emotional support provided prior to engaging in any decision making process.

Conflict of Interest:

None declared

Stakeholders in the patient who wants "everything"
Posted on September 21, 2009
Hawkin E. Woo
University of California, Los Angeles
Conflict of Interest: None Declared

To the Editor:

We applaud Quill and colleagues in tackling such a difficult and challenging topic in their article (1). We found the discussion insightful, timely and relevant. However, we feel an important step that merits recognition was not mentioned in the process: Identify and engage key stakeholders in the care of the patient who wants everything.

Quill et al direct much of the approach toward the patient and the family. Yet engagement of additional stakeholders in the care of the "everything" patient is essential for a successful discussion because many of these patients have complex health situations. Discussions about prognosis and expectations often hinge on the knowledge and assessments of these stakeholders. For a physician to embark on the discussion without engaging such key stakeholders as the primary care physician, consultant physicians, social worker, discharge planner, home health agency, nursing staff, and others would be a fool's errand. Moreover, when engaging these other team members, the physician must create a sense of ownership among these additional stakeholders that their input is critical "“ holding a family meeting for a complex "everything" patient is futile, for example, when the specialist who can best articulate prognosis and the components of "everything" care fails to show up.

As more patient care becomes teams- and systems-based, we must view the doctor-patient relationship in an expanded ecology. Identifying and engaging the stakeholders leverages the full potential of the health team and health system to benefit the patient.


1. Timothy E. Quill, Robert Arnold, and Anthony L. Back, Discussing Treatment Preferences With Patients Who Want "Everything" Ann Intern Med 2009; 151: 345-349

Conflict of Interest:

None declared

Discussing Treatment Preferences, Do Not Lead Patients To Demand "Everything"
Posted on October 22, 2009
Lawrence S. Maldonado
Cedars-Sinai Medical Center, Los Angeles, CA; David Geffen School of Medicine at UCLA
Conflict of Interest: None Declared

We applaud Quill et al. (1) for their insightful discussion of this highly relevant topic. We urge, however, that clinicians avoid asking patients (or surrogates) questions that often prompt inappropriate requests for "everything." In their case presentation, Quill et al. mentioned that, "When an intern appropriately asks about setting limits on invasive treatment.....the patient replies, 'I want everything.'" The question was inappropriate. The intern should have first explored what functional outcome the patient would have demanded at a minimum and (if this outcome were felt to be medically achievable) then explored how burdensome of a therapy the patient would tolerate to achieve this outcome and what probability of a successful outcome would warrant applying a tolerable, but burdensome therapy. Once the intern clarified these three personhood issues, he could then have outlined an appropriate medical plan and explained why that plan was appropriate both because of who the patient is and because of what his medical prognosis is.

Physicians in general--and physicians-in-training in particular-- often feel intimidated from discussing these personhood issues because they feel they lack experience in broaching these grave issues. To address these concerns, we developed a PDA based tool. The tool prompts the physician to address: 1) the minimal acceptable cognitive outcome, 2) the minimal acceptable physical outcome, 3) the maximal acceptable burden of therapy, 4) the likelihood of success which would be necessary to implement a therapy and 5) with whom or by what process these points were established. Each of these discussion points includes practical examples in the body of the PDA format to help clarify the point for the discussant. Entering the response to each query into the PDA database then generates a text summary of the patient's personhood issues for inclusion in the medical record. The database also enables review of the practitioner's experience for quality assurance and instructional purposes.

This approach to the important issues Quill et al. eloquently raise helps bring these concepts from the bioethical bench to the clinical bedside. A paucity of practical implementation tools prevents adoption of otherwise well founded principles. We encourage communication from others with additional tools to expedite wider inclusion of these valuable concepts into everyday practice.


1. Timothy E Quill, Robert Arnold and Anthony L. Back, Discussing Treatment Preferences With Patients Who Want "Everything" Ann Intern Med 2009; 151:345-349

Conflict of Interest:

None declared

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