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Problems with precision and neutrality in EOL preference elicitation
  1. Yael Schenker,
  2. Robert Arnold
  1. Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
  1. Correspondence to Dr Yael Schenker, Assistant Professor; Director, Palliative Care Research, Division of General Internal Medicine, Section Palliative Care and Medical Ethics, University of Pittsburgh, 230 McKee Place, Suite 600, Pittsburgh, PA 15213, USA; schenkery{at}

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The article by Kamm identifies ‘potential pitfalls’ in current approaches to providing patient-centred advanced illness and end-of-life care (EOLC). Specifically, Kamm cautions against ‘nudging and framing effects’ in discussions to elicit patients' preferences that could produce ‘skewed or biased results’. Kamm further argues that precision and neutrality in questions designed to elicit patient preferences may help to ensure that preferences are ‘reliably elicited’ and avoid mistakes in EOLC decisions. In response, we highlight the problems with a focus on precision and neutrality in discussions about end-of-life (EOL) preferences and advocate an alternative approach that we believe is more likely to achieve patient-centred care.

The problems with precision and neutrality

Kamm describes eliciting patients' values via precise and balanced trade-off questions, with increasingly specific follow-up questions used to pinpoint patients' wishes and ‘avoid mistakes in EOLC decisions’. This approach does not resonate with our experience conducting EOL conversations with seriously ill patients and, we would argue, it risks biasing preference elicitation for different reasons.

First, Kamm's model assumes that people have preformed preferences for EOL treatments. She suggests that the goal of the interview is to elicit these preformed preferences in a way that lets the ‘truth’ come out. In contrast, we argue that preferences are discovered in conversation, a process in which patients reflect on …

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  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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