Limitation of medical care: an ethnographic analysis.

This ethnographic study has shown how one attempt to apply ethical principles through a routine procedure failed to fit the clinical context and, in the two cases studied, served to counteract the very foundation these principles were based on--that patients or their families have the right to determine life-and-death decisions regarding code status. The results suggest that the use of well-meaning forms that are intended to facilitate decision making can, in the absence of appropriate guidelines, routinize the doctor-patient discourse to meet bureaucratic needs, narrowing rather than expanding understanding and communication. Bioethical principles implemented in abstraction, apart from the complex intricacies of the doctor-patient-family relationship and the sociocultural influences upon which this relationship is dependent, may be counter-productive to patient interests. As bioethicists and clinicians work to implement the demands of the Patient Self-Determination Act, they will undoubtedly try to forestall legal problems, assure ethical consistency, facilitate auditing, and promote documentation by creating forms. They may look to create inventories, such as the Limitation of Medical Care form described here, or turn to other, less explicit, means of documentation. This study suggests that, in these efforts, genuine attention should be given to patient concerns, not just to the ethical or institutional needs of medicine. This shift in focus from outcome to process can enhance patient and clinician satisfaction, help resolve difficulties in reaching consensus between involved decision makers, and return the power in DNR decision making to patients and families.