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won’t be used to maintain a life that can’t be rescued as was intended. Unlike most treatments, with advanced technology there are some heroic rescue situations in which it may be more likely that the patient will die or that you’ll put a patient into an adverse health state than actually achieve the intended benefit. And that has enormous implications for the level of responsibility for high-quality conversations between the treating team and the patient, or those who speak for the patient. How should physicians approach these conversations? Any physician employing such advanced technology has to understand all of the possible adverse outcomes and be able to explain them in a clear, understandable and compassionate way to patients. It’s important to identify the spectrum of potentially indicated treatments, conveying the likelihood that the treatment is going to be successful and what success would mean as well as the potential adverse outcomes, and discuss the patient’s preferences and goals. It’s also important to be realistic with families about the chances of success. Too often, patients are kept on life- sustaining treatments because families hold out hope that something might work when in reality the chances are extremely slim. These are difficult conversations. When you’re trying to rescue someone to achieve a heart transplant, the last thing that person wants to focus on is what life will be like after a massive stroke. Yet, if those conversations don’t occur, you may end up in a circumstance that virtually no patient would want to remain sustained in, without having had a clear conversation about it beforehand. What happens when the physician strongly disagrees with the preferences of patients and families with regard to the use of advanced technology or considers it to be inappropriate? That can be difficult. There is a responsibility in certain circumstances to consider invalid a request that a treatment be continued that can’t reach the intended aim. When patients feel sick and request antibiotics but the physician has a very high suspicion that this is not a bacterial process, we’ve come to the point where physicians will put up a fight. It’s tougher when life hangs in the balance, but more important. The question of what the role of individual physicians should be in stewarding the nation’s healthcare resources is complex, and to some extent these decisions need to be made on a societal level. But it is clearly the physician’s responsibility not to use an advanced technology if it can’t achieve the goal it was designed for. How about when the patient can’t speak for himself or herself and the physician feels that the family’s wishes aren’t in the patient’s best interest, or there is disagreement among family members? That happens a lot and is one reason having this conversation when the patient is able to talk is so critical. It can be problematic if some of the family views appear not to be reflecting the patient’s values. It’s incumbent upon the clinical team to sift through these differences and focus on what the patient would have wanted. Under circumstances where we know what patients would want, even if a family is voicing a different view, we will fight very hard to respect the patient’s desires. “It’s important to identify the spectrum of potentially indicated treatments … and discuss the patient’s preferences and goals.” 7 UCLA Physicians Update