Two broad categories of stressors influence complex medical decision-making, including end-of-life decision-making. System-wide and external factors like payment incentives, liability fears, and institutional productivity demands pressure physicians from the outside to behave in ways that can run contrary to patient interests. Meanwhile, relational and internal causes – communication failures, death denial, and various forms of uncertainty – do the same. Impediments to good communication and decision-making often exert their impact silently – physicians and patients may not consciously acknowledge their effects, and may even be unaware of their existence.