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(Stahlman, 1990). The federal investigations and rules may have, at least for a while, made neonatologists more fearful of forgoing life-sustaining interventions that they truly believed to be unwise (Kopelman et al., 1988).
High-profile litigation, regulations, and legislation about decisions at the end of life are uncommon but may create anxiety and fear among clinicians that have the potential to distort the way physicians inform and counsel patients and families (see, e.g., Kopelman et al., 1988). Some of this anxiety and fear is based on misunderstandings of statutes, regulations, and judicial decisions, although some may also be based on excessive caution on the part of hospital or other legal counsel and management. Efforts by professional societies, health professions educators, and organizations to improve end-of-life care may help correct erroneous views and overcome undue caution. These groups may also help to promote wider discussion and evaluation of strategies for preventing, resolving, and managing conflicts about care for dying patients.
Not all conflicts can be avoided, but they can be handled in ways that increase or decrease the potential for damage to the involved parties. Strategies include developing evidence- and consensus-based guidelines for care, improving communication skills, fostering sensitivity to cultural differences, and developing organizational procedures for identifying and defusing potential conflicts and promoting trust. Although the emphasis of these strategies will often be on physicians and parents as decisionmakers, as recommended in Chapter 4, children should be involved in discussions about their care consistent with each child’s intellectual and emotional maturity and preferences and with sensitivity to family cultural background and values.
The next chapter discusses directions for improving health professions education in palliative, end-of-life, and bereavement care. It notes that education in these issues is often restricted to ethical concerns and argues that competence in palliative and end-of-life care cannot be achieved without guided clinical experience and training that is backed by a good understanding of available scientific evidence.