Bioethics: Mediating Conflict in the Hospital Environment
Dubler, Nancy Neveloff, Liebman, Carol B., Dispute Resolution Journal
Every day physicians, nurses, other hospital staff, patients and family members struggle to reconcile differing visions, conflicting values and changing expectations as they make difficult and complex choices about whether and how aggressively to treat seriously ill patients. Often disputes arise. Traditionally hospitals have turned to bioethics committees and consultants to resolve these disputes. Below is an excerpt from a new book, Bioethics Mediation: A Guide to Shaping Shared Solutions (New York: United Hospital Fund, 2004), in which authors Nancy Neveloff Dubler and Carol B. Liebman argue that mediation should be the process of choice for solving these dilemmas. (For more information or to order a copy of the book, visit www.uhfnyc.org)
The Isolated Wife Adjusting to Loss: Edward Davidoff's Case
Edward Davidoff, an 82-year-old man, was admitted to the cardiac service with chest pain. Diagnostic tests revealed the need for quadruple bypass surgery to open four occluded vessels. He was a poor candidate for surgery, however, because he had chronic, uncontrolled diabetes with moderate-to-severe compromise of his peripheral vascular system. Unfortunately, there were no other choices if he wanted to live, which he did, and surgery was performed.
After the surgery, Mr. Davidoff did not recover and he developed various infections, necessitating his return to surgery for the removal of infected muscle and bone. A bioethics consultation was requested after the second surgery, at which time he was ventilator-dependent with an open chest wound that would not heal. Mr. Davidoff's wife was desperate about her husband's condition and determined that he should recover. She was unable to assimilate the nuanced, and not very clear, discussion by the care team, which used euphemisms to indicate that Mr. Davidoff was dying. No one in the cardiac team had been blunt about the prognosis and Mrs. Davidoff used this oblique discourse to reinforce her own unrealistic expectations about her husband's possible recovery. Completely alone and desperately lonely, she had moved her chair out into the hall and sat there waiting to waylay any staff member who came along who had any connection to the care of her husband. She responded to any specific discussion about care options by choosing the most invasive option (why that option had been presented was the first question the bioethics mediator asked the cardiac team), which she equated with the best chance of insuring her husband's survival. She was never told directly that his survival would be unprecedented, and so it is not surprising that she continued to demand that "everything be done." This demand led to the request for a bioethics consultation by the nursing supervisor, who had spent increasing amounts of time with Mrs. Davidoff.
In keeping with the usual procedure of the service, the bioethics mediator met. first with the care team-the cardiothoracic surgeon, the vascular surgeon, the first- and second-year residents, the surgical fellows, the primary nurse, and the nursing supervisor (the large care team). They discussed the case and explored the history of Mr. Davidoff's care and his prognosis, and they concurred that he was unlikely to survive the night. No one had yet communicated this prognosis to Mrs. Davidoff. Moreover, Mr. Davidoff had clearly stated to various members of the care team that if the surgery failed, he did "not want to be kept alive on machines."
The team felt that it had an obligation to the oftexpressed wishes of the patient but also to the grieving of the wife. The team members did not think that Mrs. Davidoff could manage to decide to remove her husband from the ventilator, although they felt that removal was probably what Mr. Davidoff would want. Furthermore, they felt that a do-not-resuscitate (DNR) order was needed to prevent a terrible death if Mr. Davidoff went into cardiac arrest. The open chest wound precluded any effective resuscitation effort. …