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Bioethics Mediation

A Guide to Shaping Shared Solutions, Revised and Expanded Edition

Nancy Neveloff Dubler and Carol B. Liebman

Publication Year: 2011

Expanded by two-thirds from the 2004 edition, the new edition features two new role plays, a new chapter on how to write chart notes, and a discussion of new understandings of the role of the clinical ethics consultant. **** Bioethics Mediation offers stories about patients, families, and health care providers enmeshed in conflict as they wrestle with decisions about life and death. It provides guidance for those charged with supporting the patient’s traditional and religious commitments and personal wishes. Today’s medical system, without intervention, privileges those within shared cultures of communication and disadvantages those lacking power and position, such as immigrants, the poor, and nonprofessionals. This book gives clinical ethics consultants, palliative care providers, and physicians, nurses, and other medical staff the tools they need to understand and manage conflict while respecting the values of patients and family members. Conflicts come in different guises, and the key to successful resolution is early identification and intervention. Every bioethics mediator needs to be prepared with skills to listen, “level the playing field,” identify individual interests, explore options, and help craft a “principled resolution”—a consensus that identifies a plan aligned with accepted ethical principles, legal stipulations, and moral rules and that charts a clear course of future intervention. The organization of the book makes it ideal for teaching or as a handbook for the practitioner. It includes actual cases, modified to protect the privacy of patients, providers, and institutions; detailed case analyses; tools for step-by-step mediation; techniques for the mediator; sample chart notes; and a set of actual role plays with expert mediator and bioethics commentaries. The role plays include: • discharge planning for a dying patient • an at-risk pregnancy • HIV and postsurgical complications in the ICU • treatment for a dying adolescent • dialysis and multiple systems failure

Published by: Vanderbilt University Press

Front Matter

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Table of Contents

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Foreword

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pp. xi-xii

The great promise of health reform is better-coordinated and more effective patient care, which fundamentally means more collaboration among health care providers, patients, family caregivers, and payers, over time and in different settings, to achieve the best possible outcomes. Improved information technology will help foster the necessary communication and information sharing this promise...

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Preface

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pp. xiii-xxi

This book is designed to help bioethics committees and clinical ethics consultants move to more effective clinical ethics consultation. The idea in the first edition of this book that mediation skills should be at the core of clinical ethics consultation (CEC) and that the process offers the best chance of reaching principled resolutions to difficult conflicts has now evolved into the mainstream...

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Acknowledgments

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pp. xxiii-xxiv

Although this book is primarily the collaboration of Nancy Dubler and Carol Liebman, it has been enriched by the experience and wisdom of colleagues, scholars, and practitioners. A few need special thanks. Barbara Swartz, Bruce K. Gould Distinguished Professor at Touro Law School, a scholar of health law, and an expert mediator, was on sabbatical at the Montefiore Medical Center Division...

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Part I. A Framework for Understanding Bioethics Mediation

Why does mediation hold such promise for the vital activity of clinical ethics consultation? Professionals who engage in CEC know that both process and interpersonal skills are essential for the person leading the consultation. We believe that mediation provides the best theoretical framework for understanding the process of bioethics dispute resolution and for training those who will perform...

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1. Why Mediation?

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pp. 3-20

Clarence Corning was an eighty-six-year-old male with respiratory distress. He was hospitalized for a stroke that had occurred on the right side of his brain. He was initially on the neurology service and then transferred to the acute rehabilitation service, where he had a feeding tube placed; the medical team also began treatment for pneumonia in his left...

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2. What Makes Bioethics Mediation Unique?

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pp. 21-30

Clearly, the institutional role of the clinical ethics consultation requires modifying some classical mediation practices. What is important, whether in classical mediation or in bioethics mediation, is that mediators be aware, when deviating from the model, that they are doing so and why. Even more important, mediators—in any setting—must make clear to all participants the rules under which...

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Part II. A Practical Guide to Bioethics Mediation

This is the how-to part of the book. Here we discuss issues that should be considered in establishing a bioethics mediation program. Then we organize the process into stages and identify and illustrate the techniques of mediation. Following the steps outlined here is not, however, like following a recipe. Mediators must have the flexibility and sensitivity to know when to change the order of the...

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3. Before You Begin a Bioethics Mediation Program

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pp. 33-41

In this chapter we discuss the issues to consider before beginning a bioethics mediation program: what bioethics mediators need to know, the relative importance of substantive versus process skills, the pros and cons of institution-based mediators, the hospital staff best suited to conduct mediations, the value of co-mediation, the key roles for mediators, and who can initiate a mediation. This chapter...

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4. The Stages of Bioethics Mediation

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pp. 43-72

Our descriptions represent a meld of traditional ways of describing mediation as a process that takes place in stages (Moore 2003, 66–70) with an analysis of what happens in actual bioethics mediations. Although the activities included at each stage may appear to be distinct and sequential, most mediations are far from linear. They tend to move through phases in which each party may be at a...

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5. Techniques for Mediating Bioethics Disputes

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pp. 73-91

This chapter describes techniques used in classical mediation, highlighting those especially relevant to bioethics mediators. Mediation skills training should be a hands-on experience. Most basic mediation training involves from twenty-four to forty hours of experiential, interactive instruction, ideally followed by an apprenticeship. All mediators, even the most intuitive and experienced, should...

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Part III. Chart Notes

Communicating the mediation consensus agreement regarding treatment and the rationale for that consensus, or the failure to reach agreement and the reasons for the failure, is essential to understanding the dynamics of the case. Thus, when the clinical ethics consultant writes the chart note, she takes on roles that in many ways diverge from that of neutral mediator. She becomes an advocate...

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6. How to Write a Bioethics Mediation Chart Note

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pp. 95-130

The bioethics mediation chart note has a special place in the medical record. As a subset of a note on clinical ethics consultation, it must adhere to conventions of ethical analysis and standards for best practice in clinical medicine. It must be knowledgeable, readable, clear, and descriptive of the narrative history of the case, compelling in its identification and analysis of ethical...

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Part IV. Case Analyses

Real cases that demonstrate the strengths and the weaknesses of the mediation process make up this part of the book. The three cases analyzed here come from the files of the Montefiore Medical Center Bioethics Consultation Service. “Mr. Samuels’s Case” (Chapter 7), “Mrs. Bates’s Case” (Chapter 8), and “Mrs. Leonari’s Case” (Chapter 9) tell the stories of three challenging mediations and...

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7. Mediation with a Competent Patient: Mr. Samuels's Case

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pp. 133-139

Mr. Samuels was a seventy-seven-year-old man admitted to the medical center from home with end-stage emphysema. According to Dr. Peterman, a pulmonologist who had been his community doctor for several years, Mr. Samuels was a “Damon Runyonesque character”—an irascible man who had never married, loved to gamble, and continued to smoke even after his health...

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8. Mediation with a Dysfunctional Family: Mrs. Bates's Case

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pp. 141-146

Mrs. Bates was a seventy-five-year-old patient who was transferred to the medical center from a community hospital with the diagnosis of stenosis (narrowing of the cardiac valve). Her admission had followed a series of four visits to the emergency room of the hospital near her home, where she had gone to seek help for difficulty in breathing. She arrived at the medical center with a guarded...

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9. A Complex Mediation with a Large and Involved Family: Mrs. Leonari's Case

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pp. 147-160

The first sign that a conflict was brewing was a flurry of e-mail messages. One from an administrator high up in the organization went to a hospital vice president. The note stated that the family of a patient was unhappy with the care the patient was receiving in the Surgical Intensive Care Unit (SICU). A second e-mail message between the same parties indicated that the two surgeons in charge of the...

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Part V. Role-Plays: Practicing Mediation Skills

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pp. 161-164

The role-plays in Part V are based on a combination of experience and imagination. They are designed to expose the peculiar challenges and configurations of bioethics mediation, including the multiplicity of players, the variability of motives, and the complexity of management. Neither this set of role-plays nor any text can teach all the skills that a mediator in bioethics consultations...

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10. Discharge Planning for a Dying Patient: A Role-Play

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pp. 165-171

Harold Hadoni is a seventy-six-year-old patient with colon cancer who is anxious to leave Perpetual Memorial Hospital (PMH). Mr. Hadoni had a bowel resection with a colostomy. The cancer has now metastasized to his liver and his spine, causing some bladder compromise. He requires heavy nursing care, an IV, and strong pain medication. Mr. Hadoni’s condition is terminal and he wants to...

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11. An At-Risk Pregnancy: A Role-Play

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pp. 173-178

Southend General is a busy urban hospital. Its ambulatory care center serves the many low-income residents in the area who have no other resource. Thanks to a generous long-term grant from the federal government, it has a busy maternal and child health clinic (MCHC) that provides a comprehensive set of services for women through pregnancy and into...

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12. HIV and Postsurgical Complications in the ICU: A Role-Play

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pp. 179-188

Frankie Abruzzi is a thirty-seven-year-old man currently in the intensive care unit (ICU). He admits to IV drug abuse in the past but claims he stopped using drugs several years ago. Seven years ago Frankie tested positive for HIV, and five years ago he was started on AZT. Also significant in his medical history is a heart-valve replacement several years ago due to endocarditis (inflammation...

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13. Treating the Dying Adolescent: A Role-Play

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pp. 189-196

Lucy is a seventeen-year-old Kenyan female who was diagnosed with cancer eighteen months ago. At the time of diagnosis, the cancer had invaded one kidney and metastasized to bones, lungs, liver, and aorta; Lucy’s prognosis was fairly poor given the extent of the metastases. Lucy underwent surgery to remove the diseased kidney six months prior to this hospitalization. She began a...

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14. She Didn't Mean It: A Role-Play

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pp. 197-202

Mrs. Dee is an elderly woman, critically ill with multiple medical problems, currently in the ICU. She is on a ventilator and her blood pressure is falling, even though she is on medication to support her pressure. She has had one episode in which the staff felt they might need to attempt resuscitation, but the patient stabilized and remains in the same tenuous condition. Mrs. Dee’s kidneys...

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15. Don't Tell Mama: A Role-Play

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pp. 203-211

The “they” Dr. Lowe referred to were the grown children—a son and a daughter— of the patient who had been admitted two days ago. Mrs. Gold is an eighty-two- year-old widow who was brought to the hospital by her daughter after several weeks of fatigue, weakness, and gastrointestinal disturbance. Her history and physical strongly suggested colon cancer, and a colonoscopy would be...

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Part VI. Annotated Transcripts of Bioethics Mediation Role-Plays

The four chapters that follow are annotated transcripts of simulated mediations that were conducted during the 1999 and 2010 spring semester retreats for the Certificate Program in Bioethics and Medical Humanities. We have edited them slightly for teaching purposes. The commentary added throughout the transcripts calls attention to the use of mediation skills. The mediators...

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16. An At-Risk Pregnancy: A Role-Play Transcript

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pp. 215-226

A thirty-two-year-old woman, Cindy Olsen, is in her eighteenth week of pregnancy. She and her husband, Hans, have one child, a six-year-old girl. Mrs. Olsen has had three recent miscarriages. She has been apprehensive about her pregnancy, worrying and constantly asking questions about her diet, her husband’s work environment, and her medical care. The medical team working with...

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17. HIV and Postsurgical Complications in the ICU: A Role-Play Transcript

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pp. 227-252

Frankie Abruzzi is a thirty-seven-year-old man currently in the intensive care unit (ICU). He admits to IV drug abuse in the past but claims he stopped using drugs several years ago. Seven years ago Frankie tested positive for HIV, and five years ago he was started on AZT. Also significant in his medical history is a heart-valve replacement several years ago due to endocarditis (inflammation of the...

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18. She Didn't Mean It: A Role-Play Transcript

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pp. 253-272

Mrs. Dee, an eighty-seven-year-old, critically ill woman with multiple medical problems, is currently in the ICU. She is on a ventilator and her blood pressure is falling, even though she is on vasopressors to support her pressure, and her kidneys are failing. She has had one previous episode in which the staff felt it might need to attempt resuscitation, but the patient stabilized. Mrs. Dee remains...

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19. Don't Tell Mama: A Role-Play Transcript

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pp. 273-289

Mrs. Gold is an eighty-two-year-old widow who was brought to the hospital two days ago by her daughter after several weeks of fatigue, weakness, and gastrointestinal disturbance. Her history and physical strongly suggested colon cancer, which was confirmed by a colonoscopy. Her two adult children aggressively instructed the intern not to reveal the diagnosis to their mother. Mrs. Gold is...

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Afterword

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pp. 291-292

A well-structured mediation program can resolve a current dispute and also prevent future problems. During often emotional and contentious discussions, the bioethics mediator acts as both coach and model while responding to highly charged statements and strongly held views. The way he or she asks questions, summarizes to show all participants that they have been heard, and...

Appendix

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pp. 293-310

References

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pp. 311-313

Suggested Reading on Mediation

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pp. 315-316

Index

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pp. 317-320


E-ISBN-13: 9780826517739
Print-ISBN-13: 9780826517715

Page Count: 300
Publication Year: 2011