Moral Side of Medicine
When Facing a Moral Challenge, Don’ t Go It Alone
by Lori Earnshaw, MD, FAAHPM, HMDC, & Joseph Rotella, MD, MBA, FAAHPM, HMDC
The intensivist paused before stepping into the family meeting. The nurse had told her,“ They didn’ t want to hear any talk about death.” Her patient, their patriarch, had been unconscious and ventilator-dependent for seven days following a hemorrhagic stroke. Moving on to a tracheostomy for long-term ventilatory support felt like an act of futility but the most outspoken members of this large family wanted the medical team to“ do everything.” She recognized that this situation, if not handled well, could ultimately haunt both family members and the care team. How could they navigate these complex concerns together with minimum regrets for all?*
Facing high-stakes medical decisions can be very stressful for families and healthcare professionals alike, especially when there are disagreements about the goals of care. It’ s helpful to consider not only the best course of action for the patient based on the principles of medical ethics, but also the experience of the family and care team who will have to live with the consequences. Surviving family members following death in the hospital experience high rates of post-traumatic stress, complicated grief and depression. 1 Likewise, a recent study found that more than one-third of physicians have a high level of moral distress which correlates with symptoms of burnout and intent to leave the profession or reduce clinical hours. 2 Physicians may experience an inner life plagued with doubts and regrets that is compounded by a culture of heroism that calls on them to be tough and decisive and suffer in silence. 3 But it’ s risky and not helpful to go it alone. Professionals can foster strength and resilience by engaging with an expert interdisciplinary team and following best practices in shared medical decision-making.
She walked into the conference room where a dozen family members and the palliative care team were seated in a large circle. During her preparation with the team, they had set a goal for this meeting of building trust and understanding. They would let the family do most of the talking so they could learn more about what the family hoped for and expected. When the eldest daughter said they were praying for a miracle, the chaplain asked what that would look like and how the care team could support it. The meeting ended without a decision on tracheostomy, but the family felt heard and understood and agreed to meet again the following day to discuss his medical condition and treatment options in more depth.
Physicians are wise to acknowledge they cannot control the outcome of a case: they demonstrate their positive influence by following a framework that supports shared decision-making and upholds patient autonomy. Acknowledging that conversations are a process allows physi-
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