Discussing treatment preferences with patients who want "everything".

When asked about setting limits on medical treatment in the face of severe illness, patients and their families often respond that they want "everything." Clinicians should not take this request at face value, but should instead use it as the basis for a broader discussion about what "doing everything" means to the patient. The discussion might include questions about what balances of treatment burden and benefit the patient can tolerate and about emotional, cognitive, spiritual, and family factors that underlie the request. After this initial exploration, the clinician can propose a philosophy of treatment and make recommendations that capture the patient's values and preferences in light of the medical condition. Clinicians should respond to emotional reactions, directly negotiate disagreements, and use harm-reduction strategies for the relatively infrequent instances in which patients continue to request burdensome therapy that is unlikely to help. By using this approach, patients, families, and clinicians will be better able to understand each other and join together to develop a treatment approach that best respects patient and family values in light of what is medically achievable.