- Helping a Patient Die against Family Wishes:How Should Critical Care Teams Approach Conflicting Interests in Providing Care?
It is widely recognised in clinical ethics that conversations with family members should be conducted in conjunction with ongoing treatment and that engagements should be done with sensitivity and respect for the cultural background of participants (Koon and Krishna 2014). One of the common reasons ethics consultations are requested is to help resolve conflict between care providers and family members with regards to treatment plans (DuVal et al. 2001; Back and Arnold 2005). However, if there are reasons to believe that the patient’s relatives or family members have motivations that are other than benevolent, the factual determination of details relevant to resolving conflicts is complicated. It becomes more like witnessing how protagonists will eventually overcome the wiles of antagonists in a telenovela. Truth becomes stranger than fiction and frontline care providers need to be supported if they are to succeed in giving the best care to patients. Ethics support is key, especially in mitigating and preventing moral distress experienced by those who care about doing what is best for the patient. But how do we approach cases that defy the standard paradigms our decision-making frameworks are designed to tackle?
The case of care providers’ frustrations with family members in caring for “Uncle Fred” or Mr C is one of these not-so-standard situations. We urge our care providers to be more understanding of family members’ concerns, even [End Page 146] orienting our clinical ethics consultants/committees to try to support their preferences and values. But what if it is clear that family members lack preferences and values that are consistent with the best interests of the patient? What if it is not just misunderstandings about technical details or the relative power imbalance between physician and family members?
Perhaps, we need to adopt a bioethics mediation approach as championed by Dubler and Liebman (2011). But bioethics mediation or conflict engagement (Scott 2014) will only work if the parties really want to reach an agreement (Dubler and Liebman 2011, 15). Such cases need not be declared a failure; simply another approach is better suited to resolve it (ibid.). Proponents of clinical ethics counselling suggest openness to a variety of approaches (Linkeviciute and Sanchini 2016). The objective of this commentary is to explore how care providers should approach caring for patients when family members are perceived to have motives that are other than benevolent or if they lack genuine concern for the best interests of the patient. In addition to exploring process options specific to critical care, we will explore a values-based decision-making framework (Duthie et al. 2014; Jiwani 2015) that may help in the search for appropriate approaches to similar cases—that is, situations where there are reasons to doubt the motives of family members.
Should We Always Follow the Wishes of Family Members?
In a Confucian-inspired, family-centric society like Singapore, it is by default important to make clinical decisions that are mindful of the wishes of family members (Ho et al. 2010; Krishna 2011). In this context, the family is considered to be the most basic autonomous unit within society (Ho et al. 2010). What makes this cultural system work is the assumed moral belief in filial piety or the obligatory duty of family members to care for their elders, which is supposed to be driven by a reciprocal appreciation of the care they had previously received from them (Hamilton 1990). From the perspective of the care providers, in the case of Uncle Fred, family members do not fulfill this duty. Could it be that the care providers have misunderstood the intentions of the family members? In other words, is their desire not to withdraw treatment a sign that they do not want to abandon the patient, as prescribed by the virtue of filial piety? If so, then it seems appropriate to explain to family members that ending suffering and allowing peaceful, dignified death is also a way to fulfill filial piety, especially if doing so is consistent with the dying wishes of the patient. This may prove difficult as life support is...