Ambiguity at the End of Life: Clinical Heuristics and the Problem of Terminal Illness

This paper examines how clinicians in Hospice and Palliative Medicine (HPM) help patients and colleagues resolve ambiguous clinical situations at the end of life. 'Clinical ambiguity' is advanced as a concept to describe how the heuristics used to match medical knowledge to patient interests produce diverging imperatives when patients are terminally ill. Separate from uncertainty, clinical ambiguity captures not a lack of definitive information or knowledge, but the limits of routinised knowledge and practice when applied to patient care. HPM clinicians, typically at the request of other clinicians, reorient decision-making around normative concerns-what ought to be done-rather than relying on descriptive clinical facts. This approach departs from dominant medical models that privilege impartial, fact-based reasoning. Using interviews with clinicians in the United States and ethnographic observations at a large teaching hospital, this paper shows that HPM's distinctive role at the end of life, foregrounding patient preferences, creating shared understanding and establishing achievable goals, derives not from clinician virtues or failures but from this speciality's structural niche in the division of medical labour.