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Health Care Ethics USA Conflict Between Families and Providers: Avoiding Treatment Disputes Conflicts involving end-of-life treatment decisions can demand an inordinate amount of a health care professional's time. Providers desire to avoid conflict, for decisions must be made whether or not to continue treatment and, if so, which interventions to continue. Prolonged disputes can be emotionally unsettling for physicians and nurses and for patients and their families.1 One can think of conflict over health care as an intersection in which four busy streets come together. Traffic planners take great care to add safeguards to help prevent accidents at intersections. They might upgrade traffic lights, add turning lanes, or decrease speed limits. Similarly, four "streets" intersect when end-of-life decisions must be made: the nature of health care, family dynamics and functioning, the interaction between families and health care teams, and the influence of culture on medical decisions. These four factors, akin to four converging streets in a city, lead to the intersection of conflict. If health care providers don't give proper regard to the intersection of these four elements, the result can be the administration of inappropriate treatments, caregiver burnout, dissatisfied patients and/or families, and legal action. In first part of this essay, several ethical principles and concepts involved in end-of-life treatment disputes are described. Then, each of the four factors leading to the "intersection" of conflict is discussed. Finally, strategies are suggested for avoiding end-of-life treatment disputes. This paper specifically addresses conflict between providers and patients' families; however, much of the following could apply to conflicts with non-family surrogates as well. Principles Several makes and models of cars head toward a busy intersection. Similarly, end-of-life treatment disputes involve clashes between various principles and concepts. An example of such a clash occurs between patient autonomy and provider autonomy. Medical decision-making in the United States has placed great value on the principle of respect for patient autonomy. Western medicine grants patients the basic right to say what happens to their own bodies, but problems arise when an incompetent patient has not designated a surrogate and state laws do not clarify who the decision-maker should be. Even if a surrogate is known, family members may disagree about the proper course of action among themselves. When a patient demands treatment with an ineffective drug that is outside the bounds of standard care (e.g., use of an antibiotic to treat a cold), respect for provider autonomy gives the physician the legitimate right to refuse; however, ethical boundaries become murky when families insist on inappropriate treatments. For example, a family might demand that an antibiotic be prescribed to treat pneumonia in a comatose patient who has terminal metastatic liver cancer. In this situation, the patient's interests and wishes (ostensibly represented by the family) and professional authority and judgment may conflict. In addition to autonomy issues, there also may be different understandings of what is good for the patient and hence what constitutes beneficence. The family's desire to do what it thinks best for the patient may conflict with the provider's sense of appropriate and inappropriate care. Families of patients are often involved in end-of-life decisions because patients want them to be. A public opinion poll showed that 30% of respondents wanted their families to make medical decisions should they lose the ability to make decisions of their own. Fifty-three percent wanted their families to decide in concert with their physicians. Therefore, adding these two statistics together, a notable 83% want families involved in making decisions if they are unable to.2 Many physicians willingly seek family consent because they do not want to make important end-of-life decisions alone. However, health care literature often depicts families as extraneous to the care of the patient. A persistent tendency is evident to equate families with trouble.3 The patient-centered perspective in health care may be rooted in the Western focus on patient autonomy and the sanctity of the physician-patient relationship. Thus, the high value that most patients place on the importance of the family being involved in treatment decisions can conflict with the traditional emphasis on patient autonomy. The concept of medical futility can be viewed as conflicting with the principle of the sanctity of human life. Schneiderman, Jecker, and Jonsen have defined medical futility in two ways: "when physicians conclude that in the last 100 cases, a medical treatment has been useless" (quantitative),4 or "if a treatment merely preserves permanent unconsciousness or ... fails to end total dependence on intensive medical care" (qualitative). However, some families might feel that medical futility is an excuse used by the health care team to devalue the life of a patient so that treatment can be stopped. For some family members, futility may imply an uncaring or indolent attitude, whereas the medical team, in reality, highly values life and desires to provide the best care for a patient. On the other hand, providers may be suspicious when individuals openly assert strong pro-life views because estranged family members have been known to use sanctity-of-life arguments to inappropriately prolong the life of patients so that reconciliation might take place. Therefore, misconceptions on the part of families and on the part of providers can lead to a clash between medical futility and sanctity-of-life arguments. Discussion The first street, or factor, involved in the dynamic of provider treatment disputes with families is the nature of health care itself. In order for families to exercise their responsibility to make treatment decisions, they must have access to understandable information about the patient's condition. Unfortunately, obscure medical terminology can complicate the decision-making process. Most people have little medical training, and even the simplest medical term can cause confusion. Large health care teams, with shifting or changing members each trained in separate professions and specialties, also can fracture communication between providers and families. A hospital may easily have different physicians on duty from week to weekend, or even from one day to the next. Each brings differing experiences and expertise to the case. Sometimes sincere differences in opinions in diagnosis and treatment occur between physicians. A nurse may insist a treatment is beneficial which a physician thinks is futile, or vice versa. These inconsistencies and ambiguities increase the potential for conflict. The second street leading to the conflict intersection is the perplexity of family dynamics and functioning. Several causes contribute to the potential for conflict between family members, or between the family and the health care team. For example, family members are placed under extreme stress when making medical decisions. Sometimes the family may have to rely on advice given by a younger family member who has medical training, rather than on advice from established family leaders. Several family members might have had to travel great distances to the bedside and are lacking adequate rest. For some family members, the threatened loss of a loved one may open up unhealed wounds from the past. Taking all this into account, families in crisis often have difficulty processing and retaining information therefore contributing to the potential for conflict. Problems caused by the interaction of families with health care teams are the third street. Some providers may be wary of involvement of family members in health care decisions because families might seem to interfere with traditional physician-patient relationships. Providers might cast a wary eye at certain family members, thinking that they might lobby for treatment decisions based on their own best interests rather than that of the patient. Even though physicians might believe that a certain family is committed to doing the right thing for a patient, the question remains open whether or not family members always know how to do the right thing for a patient. On the other hand, families may view the health care team as outsiders who do not really know what their loved ones would have really wanted. This potential for an atmosphere of uneasiness between providers and families could lead to conflict over medical decisions. The fourth and final street leading to conflict is the influence of culture on medical decision-making. Culture is a strong determinant of people's views of the very nature and meaning of suffering, illness, and death. Illness may have a spiritual meaning for some. For example, in the Christian tradition, suffering can be given a constructive meaning by relating it to the cross of Christ. In non-Western cultures, interdependence might be more highly valued than individual autonomy. Cultural differences and language barriers can often cause simple communication errors. Bowman relates a situation describing why a female family member felt that an ICU physician's attitude toward her mother was "cold." She became upset because he twice referred to her mother as "him." The physician, who was from China, later confessed to others that he was nervous. The third person singular personal pronoun in Chinese has no gender distinction. So when he became nervous because the meeting wasn't going well, the physician defaulted back to this characteristic of his native tongue and called the mother "him." Just as traffic lights, sand-filled barrels, and seat belts are used to prevent or minimize the effects of accidents, so there are various strategies for minimizing or handling treatment disputes at the intersection of the four "streets." Rather than speaking of futility when discussing the appropriateness of a medical treatment, physicians might want to explain the idea that when benefits outweigh burdens of treatment, treatment may be appropriate, but otherwise not. Providers should not hesitate to explore a family's perception of their loved one's illness. They could enable the family to share their feelings about the patient. The team might encourage the family to contact friends, other family members, or religious leaders such as pastors, priests, or rabbis. Chaplains or social workers can provide additional on-site support. Providers may strive to foster and assess family coping mechanisms on a psychological level (e.g., unresolved issues), on an interpersonal level (e.g., support), and on a sociocultural level (e.g., deathbed rituals). There are several hazards the health care team might want to avoid when interacting with a patient's family. Having a patient-centered perspective and not viewing the family as an integral part of a patient's identity and life raises an attitude of mistrust for the provider by the family. Members of the health care team also need to avoid being impatient and giving the impression they are not approachable. A provider should seldom give unexpected news by phone, for there is too much potential for miscommunication without personal contact. Because medical practice consists of many procedures, physicians might be tempted to view a family meeting, in which withholding or withdrawing treatments will be discussed, as just "one more thing to do." Rather, it's advisable to present treatment decisions to families as just one aspect of an overall plan of care. When speaking with patients or their families, it is wise to avoid certain words and phrases that may become stumbling blocks during the discourse. The word "futile" is a technical term in medicine, but to families it might imply that a patient is not worth the effort of comprehensive care. A phrase like "it's time we talk about pulling back" can insinuate abandonment, or describing CPR as "doing everything" may suggest that, if a do-not-resuscitate order is written, the medical team is doing nothing. Rather, physicians could open a family meeting by reinforcing the goal of appropriate health care with these words: "We can hope for the best, but we also need to plan for the worst." Conclusion Difficulties in family functioning can be amplified by medical complexity, poor communication, or discrepancies between caregiver statements. Accurate communication is vital between families and providers when end-of-life treatment decisions are being made. Providers must remind themselves to give frequent updates to families in simple language. Patience is vital; families often need time to understand and accept the situation. Providers should affirm that they will never abandon the patient. Health care training in cross-cultural differences, team building, communication, and conflict resolution would help. Health care organizations need to improve policies and procedures for improving team functioning, facilitating communication, and dealing with potential conflict. 
Kevin E. Voss, M.Div., D.V.M.
Questions For Discussion
Suggested Readings Lo, Bernard. "Chapter 13. Surrogate Decision-Making." In Resolving Ethical Dilemmas: A Guide for Clinicians, 2nd ed., pp. 111-17. Philadelphia: Lippincott Williams & Wilkins, 2000. Von Gunten, Charles F., Frank D. Ferris, and Linda L. Emanuel. "Ensuring Competency in End-of-Life Care: Communication and Relational Skills." JAMA 284, no. 23 (December 20, 2000): 3051-57. Weijer, Charles, Peter A. Singer, Bernard M. Dickens, and Stephen Workman. "Bioethics for Clinicians: 16. Dealing with Demands for Inappropriate Treatment." Canadian Medical Association Journal 159, no. 7 (October 6, 1998): 817-21. |
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