End-of-life care in hospital: how can doctors and nurses discuss differing beliefs?

What staff actually disagree about

When doctors and nurses disagree about end-of-life care, the first step is to establish what the disagreement concerns: the goal of care, the prognosis or a particular procedure. A clinical assessment calls for a different justification from a personal belief about what should be done. The team should also record separately how each person understands the patient’s wishes. An umbrella review of 19 reviews of nursing studies describes moral distress associated, among other things, with treatment considered futile and with the team’s working conditions. It does not, however, resolve an individual case: the studies varied, and the strength of the conclusions depends on the quality of the original research. Separating these issues helps people talk without calling a colleague with a different view less empathetic.

The patient’s voice

Before the team discusses its own beliefs, it should return to what the patient has said about their goals of care and concerns. It helps to establish when the patient said this, whom they told and what they shared with their family. What a patient says is not the same as their loved ones’ interpretation, even when that interpretation comes from concern and a close knowledge of the patient’s life. When communication is limited, the team needs to check what options are available to confirm the patient’s preferences rather than assume they are already known. Only then can differences among staff be explored. The question becomes not just “What do we want to avoid?” but also “Which goal mattered to the patient?”

When camps form

When “two camps” form within a team, discussion can easily shift away from the evidence and risks to the patient toward assumptions about colleagues’ intentions. A better approach is to ask each group to identify the information it considers decisive and the risks of its proposed course. A different view of treatment is not, in itself, evidence of a lack of care. A meta-analysis of 31 studies involving 7,635 nurses found a negative association between ethical climate and moral distress. This is a correlation, not proof that a single training session will reduce distress or explain a particular dispute. Clarifying the reasons behind each position can, however, show whether the sides truly differ in their values or simply have different information.

Team consultation

A consultation needs a facilitator and a clear understanding of whose input is needed to present the patient’s condition, preferences and care-related concerns. The facilitator can set out, in turn, the established clinical facts, uncertainties and questions the team has yet to answer. The patient’s documented preferences should be distinguished from interpretations of them, and a clinical decision from a question requiring a separate ethical or legal consultation. Not every uncertainty will be resolved around one table. Before closing, the team needs to decide how to document the reasons for its conclusions and who will explain the outcome to the patient or family. This structure does not erase differences in belief, but it makes it harder to confuse a staff member’s personal view with their professional responsibilities.

The limits of international research

International research can help identify how staff experience end-of-life disagreements, but its limits must be kept in mind. A Spanish qualitative study based on interviews with 25 people examined healthcare professionals’ views on medical assistance in dying in the Spanish context. A correction to the publication was noted. This material describes participants’ experiences; it does not establish procedures for every hospital and has limited applicability to the Polish context. It should therefore not be used to infer a legal rule or presented as an interpretation of patients’ rights in Poland. In a team discussion, it can help raise questions about sources of tension, not replace an appropriate consultation.

When the team remains divided

If the team remains divided after consultation, disagreement should not interrupt the patient’s ongoing care. The team needs a shared plan for now, someone to communicate it and a way to pass on new information relevant to the decision. Concerns requiring further assessment should follow the facility’s appropriate ethics consultation pathway; legal questions also need to be clarified separately, rather than settled by voting on beliefs. The team should agree when to revisit the decision if new information emerges about the patient’s condition or preferences. That way, temporary disagreement means neither inaction nor a pretence of unanimity.

After the decision

After a decision, the patient or their loved ones should receive a consistent explanation of the plan and have an opportunity to ask questions. Within the team, it is worth checking that everyone understands what was agreed and knows how to raise another concern or share new information. Staff should also be asked about difficulties in carrying out the plan, whether these involve unclear tasks or lingering tension. Looking back at the discussion can show what should be clarified earlier next time and whether the patient’s voice was sufficiently heard. It should not become a public judgment of one person’s values. The team then learns from the process, not from labels applied to colleagues.

Disagreement about end-of-life care need not divide a team into “empathetic” and “unempathetic” staff. It helps to separate clinical facts, the patient’s preferences and staff beliefs, then agree on how to continue the conversation.

Empatyzer in conversations about end-of-life beliefs

When a hospital team is preparing to discuss a patient nearing the end of life and its members see the priorities differently, they can first use Em to frame questions about the patient’s values and points that need clarification. The facilitator can prepare a question about the source of the disagreement: is it a different assessment of the evidence, a different goal of care or a personal belief? Em can also help phrase a statement that separates staff values from the goal the patient identified. When preparing a consultation, team mode helps arrange the order in which members of different professions speak, so no perspective is overlooked simply because it comes later. The “About me” feature helps staff notice their own reaction to someone else’s position before speaking. Micro-lessons can support practice in paraphrasing: first checking that I have understood a colleague correctly, then responding. These steps give the conversation structure, but they do not replace clinical assessment, establishing the patient’s preferences or an appropriate consultation.