Clinicians face pressure to "keep going"
Disagreements are barriers to treatment abatement
Clinicians may face pressure from family members to "keep going" when there is concern that the patient might not have wanted aggressive end-of-life interventions, or the health care team considers palliation in the patient’s best interests. "This is very common," says Nancy M. P. King, JD, co-director of the Center for Bioethics, Health, & Society and Graduate Program in Bioethics at Wake Forest University in Winston-Salem, NC.
Failures of communication are often at the root of these disagreements. "This probably accounts for the majority of ethics consultations in many health care facilities," says King. "It is less common for families to know that the patient’s advance directive requests treatment abatement and nonetheless seek to override those end-of-life wishes, but it certainly occurs."
Usually, this isn’t because families disagree with the patient’s wishes, however. More often, families misunderstand or resist understanding the patient’s condition, argue that the patient would have made a different decision about his or her current circumstances, or misunderstand the chosen health care agent’s decision-making authority or the meaning of substituted judgment."Family members’ grief and guilt are often barriers to treatment abatement that may manifest as simple disagreements," says King. She recommends these approaches:
• The health care facility should have a continual process of education for clinicians and legal counsel about advance directives, advance care planning, and end-of-life decisions.
Clinicians who understand their facilities’ policies and the applicable law are more likely to seek consultation, and less likely to override advance directives. "Legal over-caution is often the reason for listening to the family rather than following the patient’s wishes, but that over-caution is rarely justified," says King.
• The team should identify and support the patient’s named agent.
"This is as important as identifying the patient’s wishes," says King. "Support and counseling for the family is equally essential in every instance." Families need to know that their acquiescence with the patient’s wishes is neither "giving up" nor "killing" a loved one.
Even when patients have informed families of their wishes, that discussion may not have been enough to reassure the family about honoring those wishes. "Additional supportive counseling may help," King suggests.
• The team needs to know that they have an absolute duty to provide aggressive palliative care to patients in these circumstances, regardless of family objections.
This is especially important if the decision-making process is contested or resolution of the conflict is delayed, even if the facility ultimately supports the family’s choices. "Patients must be kept comfortable, no matter what else is in the treatment plan," says King.
Nancy M. P. King, JD, Co-Director, Center for Bioethics, Health, & Society/Graduate Program in Bioethics, Wake Forest University, Winston-Salem, NC. Phone: (336) 716-4289. E-mail: email@example.com.