Family physicians can work to achieve Common Ground with substitute decision-makers of dying patients as a means to prevent and/or manage conflict and facilitate the mutual goal of achieving a “good death” experience for everyone involved. Through our exploration of family physicians’ conflict with substitute decision-makers, we developed a cohesive, practical approach that could assist clinicians with finding Common Ground with surrogates when providing care to dying patients. “Common Ground” is a key element of the Patient-Centered Clinical Method in Family Medicine as conceptualized by McWhinney . He describes “finding Common Ground” as a “process of clarifying issues, encouraging the patient’s questions, and seeking his or her agreement with the plan” . The specific facilitators and barriers identified for each step in our framework for managing conflict with substitute decision-makers of dying patients was found to fit McWhinney’s more general description of finding common ground within the Patient-Centered Clinical Method . This further supports our framework since entering these various indicators and concepts into our framework lead to the same core variable of Finding Common Ground. This supports the Glaserian grounded theory concept of “inter-changeability of indicators” since other indicators can be incorporated or explained by our framework, indicating that the framework is relatively complete .
Our framework emphasizes that this process of achieving Common Ground relies on time as the ultimate facilitator. Multiple contacts with the surrogates are required to deliver and discuss medical information in manageable quantities. Multiple contacts over time also foster the formation of a trusting relationship between the physician and the surrogates so that each can start to understand each other effectively. There is great benefit to facilitating the family and substitute decision-makers through their grief process to improve the collaborative, shared decision-making process. Not only does the physician need to help surrogates understand the reality of the patient’s medical situation, but also, there needs to be time, acknowledgement, and support given for the family to grieve the loss of their hopes for the future with the patient, even prior to the death. As it is the family who will need to be able to live with their decisions beyond the patient’s death, decisions made should not increase their risk of developing future anxiety or depression [10, 11]. Thus, embarking on this process to achieve Common Ground should be initiated at the first contact of the healthcare team with any surrogate, ideally before any conflict has arisen. Each of these detailed elements provide the foundation for the physician, the healthcare team, and substitute decision-makers to work together effectively, and prevent or manage any conflicts so as to make informed decisions which will optimize the achievement of the patient’s “good death”.
Unfortunately, just as time is the ultimate facilitator for this process, it is also the ultimate barrier. At any point of this process, a lack of time prevents conflicts from being effectively resolved, and an impasse could occur. Further contributing factors to an impasse also emerged from our study and some of these concepts support what has already been described in the literature.
Unrealistic expectations and loved ones’ denial of the patient’s condition were both identified as fundamental barriers to achieving Steps 1 and 2 (Figures 1, 3 and 4). Managing these helps to close “Calman’s gap” as defined earlier [5, 6]. This may also be an indicator that both the physician and surrogates are being understood. Hence, achieving the ideal situation of matching expectations could facilitate finding Common Ground. Matching expectations are indicators of the concept of closing “Calman’s gap” [5, 6] which, to some degree, represent our concept of achieving Common Ground. This is again evidence of an inter-changeability of indicators, and supports our findings .
Even when other identified barriers to Steps 1 and 2 in Figure 1, such as family discord or dysfunction, mistrust of the medical system, language barriers or cultural value differences (Figures 1, 3 and 4), can be reconciled, there may still be difficulties with decision-making due to absent, or ineffective advance care planning with the patient. A lack of preparedness for the role of a substitute decision-maker, and a lack of clear understanding of using true substituted judgement [26, 27], (whereby the surrogate is responsible for making the medical decision that the patient would have made), further increases the risk for irresolvable conflict to lead to an impasse. These were identified as the key barriers to achieving Step 3 in Figure 1.
The specific approach to resolving an impasse in this study has not been previously described. This approach to managing an impasse gives permission to consider transferring care as a viable management option, if multiple genuine attempts to resolve conflicts have been unsuccessful. When a physician feels that ongoing conflict may actually either affect patient care, cross a physician’s personal moral boundary, or cause a loss of the affective neutrality imperative in a doctor-patient relationship, a “hand-off”  of the patient and the surrogates to another physician could be accepted as an appropriate method of termination of the therapeutic relationship . This allows a fresh start to occur for all involved , and may ultimately improve the chances of the end goal of a “good death” to still be accomplished. A large European survey showed that physicians often perceive ethical difficulties related to a patient’s impaired decision-making capacity (94.8%), or disagreement with caregivers over making decisions for incompetent patients (81.2%) . Thus, the framework of how to approach an impasse, with the option of transferring care, may help physicians to better cope with these difficult dilemmas and foster effective relationships with surrogates of dying patients, thereby increasing job satisfaction and decreasing job stress .
Our results underscore what has been recommended for the last decade about educating the general public about death, dying, and planning for this eventuality . Richard Smith , remarked in a British Medical Journal editorial that health services need to change its view of death and dying so as improve the chances for achieving good deaths. He argues: “If death is seen as a failure rather than as an important part of life then individuals are diverted from preparing for it and medicine does not give the attention it should to helping people die a good death” . If society as a whole was better informed about the dying process, conceivably, this would help facilitate more open discussion about end-of-life care and wishes . The framework described in this study may help in educating the public on how to have these discussions effectively with healthcare providers and surrogates, and to not delay these conversations. Perhaps then, terms such as “code status” or “Personal Directives” will not be seen as “icons of death”, but rather an opportunity to delineate one’s definition of a “good death”.
Family physicians are in an ideal position to guide patients through the advance care planning process and to encourage their potential surrogates to actively participate. In the 2004 Ipsos-Reid survey  on Canadian Hospice Palliative Care, 44% of Canadians had discussed their EOL wishes with family, and only 9% had discussed these with their physicians. Family physicians can take advantage of their established relationship to determine how best to broach these sensitive end-of-life issues with each patient, and positively influence death experiences for patients and their families. Since primary care physicians or family physicians are best trained to treat the whole person, and to coordinate care within the healthcare system, they are “the best prepared of all physicians to hear and implement patients’ wishes regarding care” . Even when a patient must be transferred to a care facility where the family physician cannot continue to be the primary attending physician, the early work that the family physician may have done with the patient and substitute decision-makers in delineating his/her end-of-life wishes can still be of benefit. “Informational continuity”  can result through the direct transfer of this information, including the patient’s values, beliefs and any specific end-of-life preferences, from the family physician to the new attending physician. With this transfer of information, the key foundational work that the family physician will have furthered can then be built upon. The next steps in any conversation regarding a patient’s wishes may then be less overwhelming to the surrogates because the concepts will not be wholly foreign. Thus, Common Ground may be attained more efficiently for the next provider. This concept may be generalized to other primary care providers, such as general internists, and primary care nurse practitioners.
A major barrier to pre-emptive advance care planning is the amount of time required to have these conversations with patients and their surrogates. Family physicians need to be financially supported to take the time necessary for these complicated discussions. This seems even more urgent given Canada’s aging population. An Ontario study found that detailed advance care planning can save health care costs in nursing home facilities . This argues for the economic benefits of financially supporting Canadian family physicians to implement detailed advance care planning for all of their patients as part of their comprehensive practice.
Limitations of study
This study involved family physicians who work only in Northern Alberta, Canada. While the participants work in a variety of clinical settings, the findings of this study may not be applicable in other clinical settings, or different healthcare systems.
Initially, the research team had preconceptions and possible selection bias which may have limited exploring the experiences of those who did not perceive having had conflict. Perhaps those who did not perceive conflict with surrogates have refined skills in preventing or handling conflict.
Ethical constraints inhibited interviews with substitute decision-makers and dying patients to provide further insight.
Future work may include further theoretical sampling with family physicians who self-report not experiencing conflict to gain more insight from their perspectives. Theoretical sampling of intensive care specialists, nephrologists, oncologists and others who work closely with dying patients, to explore the ways in which they manage conflict with surrogates of dying patients may be beneficial. Studies with other primary care providers would further the insights gathered from this study.
Initiatives are necessary to encourage and facilitate family physicians to foster their unique relationships with their patients, and to commence these important end-of-life conversations so as to help their patients achieve “good deaths”. Effective methods to improve “informational continuity”  of advance care planning within a healthcare system are required as well.