Situating end-of-life decision making in a hybrid ethical frame.

Good communication in EOL (end-of-life) discussions is described at a general level in the literature, but there are few studies of EOL discussions at the level of interaction, with data drawn from the actual talk between physicians and families. In this article I present a discourse analysis of EOL discussions from an American ICU (intensive care unit) where the decision to withdraw life support is situated in a hybrid ethical frame co-constructed as the final phase of the EOL discussion. In Mishler's (1984) terms, the final phase of the EOL discussion merges the voice of medicine and the voice of the lifeworld, with both physicians and families initiating, developing, and repeating particular topics that encompass not only the logistics of death but also the ethics of the end-of-life decision. Physicians index their ethical accountability in terms of medical futility, and families express their accountability in terms of an ethics of consciousness. The hybrid ethical frame that is co-constructed ultimately centers upon consensus that the 'right' decision has been made from both ethical perspectives.