Ethics Conflicts in Rural Communities: End-of-life Decision-Making (PDF)


Dartmouth College Medical School Department of Community and Family Medicine


Caring for people at the end of their lives can be one of the most challenging and personally rewarding aspects of primary care. The proximity to death intensifies and transforms the medical encounter calling upon both the emotional and the clinical competence of the medical provider. As people live longer with chronic illnesses, and as life-prolonging interventions become routine, death frequently involves a decision to forgo or limit care. Such decisions can generate moral conflict, even when the ethical and legal principles governing decisions are well defined and widely accepted. Family members, may feel that withdrawing life support is morally different than withholding such therapy in the first place. Surrogates named in advance directives may want to keep their loved ones alive rather than follow directives, even when the patient’s wishes are clearly articulated. The clinician’s responsibility is to support the autonomy of the dying person, while recognizing the emotional needs of the family. This has become more challenging in cases where there is no ethical consensus about either the decision to be made, and/ or the legal requirements for its enactment, such as the withdrawal of artificial nutrition or terminal weaning from a ventilator. Ethical challenges in end-of-life care are heightened for rural providers who often have multifaceted relationships with patients and their families. Rural providers are sometimes the sole recipients of oral directives, and may have less experience than urban providers with complex end-of-life care. Rural clinicians should enact procedures to help their patients and patient’s families prepare for the end-of-life process to reduce both ethics conflicts and undue stress for all parties involved.

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Denise Niemira, Tom Townsend

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Rural_Palliative_Care.pdf 215.11 KB