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147 9 A Complex Mediation with a Large and Involved Family: Mrs. Leonari’s Case Background 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 unit were in dispute about the care the patient should receive. A third message, a response from the vice president with the previous e-mail correspondence attached, suggested that the Bioethics Consultation Service be called in to the case. On that same day, the nursing supervisor in the SICU called the bioethics mediators for the hospital, requesting a bioethics consultation. The reason provided for the request, a bioethics issue, was that the family was interfering with the appropriate care for the patient and the interests of the patient were imperiled. The two bioethics mediators who picked up the case, Andy Purdure and Virginia Lieland, agreed that a principled frame for the problem would probably be that the patient’s well-being was in jeopardy and that the obligation of the staff to pursue the best interest of the patient, a principle called beneficence, was threatened . As a matter of course, the ethical obligation of the staff to care for the present needs of the patient defines appropriate care. Family interference with the standard of care is always troubling. A second bioethics issue inherent in the initial narrative was the allocation of scarce resources. A bed in the SICU is a scarce resource that must be allocated fairly and is generally assigned according to the principle of triage—a bed to that person who can benefit the most, who is neither too sick to benefit nor too healthy to justify this level of care. The staff in an intensive care unit is also a scarce resource. A patient’s family that is too demanding and takes up a disproportionate amount of time and energy deprives other patients of the care that they require. 148 Bioethics Mediation: A Guide to Shaping Shared Solutions This bioethics mediation team usually begins the mediation process by speaking with the referring person, reviewing the chart, and convening all the care providers. In general, this initial meeting comprises four to six staff members who brief one or more of the mediation team on the case, describe the medical condition of the patient (history, diagnosis, prognosis), relate the interactions with the family, and express whatever emotions are clouding the creation of a successful and shared plan of care for the patient. This case was unusual from the start: eighteen staff members gathered in one of the empty rooms of the SICU. Participants included the two surgeons in charge of the unit, the supervising nurse and six nurses from the unit, two physician assistants, the two surgical fellows, one social worker, and four house staff and medical students. The emotional maelstrom was immediately apparent, indeed overwhelming. The first step in any classical mediation, setting the stage or arranging the participants around a table, is rarely possible in bioethics mediations and was not possible in this case. Staff rolled chairs over from the nurses’ station, the bank of monitoring machines, the other patient rooms, and the adjoining medical service; three or four sat on the empty bed; others leaned against the windowsill. One of the surgeons sat, but the other one, concerned about the care of another patient who was in crisis, stood in the doorway to have a clear view of a particular monitor. Mr. Purdure and Ms. Lieland began by using their standard protocol: introducing themselves as bioethics consultants and mediators and asking the person who called the consult to explain why in this case she had thought there was an ethical problem. The supervising nurse explained that the nursing staff was so distraught over the behavior of this family and so fearful of them because of their complaints to supervisors and administrators that they were reluctant to care for the patient; the staff continued to provide excellent care, she hastened to assure everyone, but she was concerned that this family’s behavior was on the verge of compromising the patient’s care. Drs. Kibbe and Lordson, jointly in charge of the case, then explained that indeed there was...

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