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By Allen Jeremias; David L Brown

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The physician often must read between the lines and recognize subtle cues about what matters most to patients and their loved ones. Effective communication prevents and defuses conflict; helps patients and families work through their anxieties, fears, and anger; and is the most important skill in negotiating the difficult ethical dilemmas that arise in the ICU. 13 2 Introduction Establishing effective communication requires time and planning. Physicians must remind themselves that although ICU care may become routine for them, it is rarely that way for the patients or their loved ones.

These laws set standards for several types of documents, but primarily living wills and medical powers of attorney. Collectively, these documents are known as written advance directives. These documents usually have legal standing only within the state where they are completed, and only if they conform to the state's statutory language, although some states grant some degree of validity to other states’ advance directives. These documents can assist loved ones and health care professionals in determining what an individual would have wanted, especially if the patient has an irreversible condition such as a terminal illness or a persistent vegetative state.

At times of critical illness, grief-stricken or guilty family members may press for disproportionate treatment as a way to relieve their own distress. An open and understanding exploration of the underlying feelings usually resolves such ­difficulties. 20 Sometimes an honest disagreement persists: what seems disproportionate to the physician seems reasonable to the family. Several guidelines can help in such circumstances: (1) the physician's primary responsibility is to the patient; (2) in most cases, the family has the patient's best interests at heart and knows the patient better than the medical team; (3) ethicists, chaplains, social workers, and ethics committee members can assist in facilitating an agreement on the treatment plan; and (4) care can sometimes be transferred to a physician who agrees to comply with the family's wishes.

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