Abstract
Background
Clinicians frequently encounter incapacitated patients whose decisions must be made by a surrogate decision-maker (SDM) or SDMs. Even when there is a single official SDM, family conflict can be a source of distress for the surrogate, family, and clinicians. When there are multiple SDMs with equal say, conflict is more problematic, as it may preclude reaching a decision. This Fast Fact provides guidance on helping clinicians mediate surrogate disagreement.1–4
Preparing for the Conversation
Confirm the patient lacks capacity and that an SDM is genuinely needed (see Fast Fact #55). Determine where the legal decision-making authority lies. Is there a single SDM designated in an advance directive (e.g., health care power of attorney)? If there are multiple potential surrogates, who comes highest in the hierarchy? If there are multiple surrogates at the same level of the hierarchy, does the state require a majority or unanimity? Recall that even if there is a single legal SDM, some surrogates may be uncomfortable reaching a decision without family consensus. Gather information with a curious mindset. What are the family and interpersonal dynamics? How have they handled conflict in the past? How do they usually make medical decisions together as a family? What is each family member’s relationship with the patient like? Use an interprofessional approach. Many social workers are trained in family systems theory and have specialized skills in family dynamics. Nurses often have more direct observations on how family and loved ones interact. Chaplains can identify unique spiritual values and partner with SDMs. Give clear and consistent information. When many clinicians are talking to various family members, misunderstandings are common. It is helpful to present a unified message from the different disciplines and professions caring for the patient. A family meeting with representatives from different care teams, as well as a “premeeting” beforehand, can help align clinical messaging. Consult palliative care early on.
Mediating the Conversation
Center the patient’s voice. Clinicians should help family members reflect on the patient’s goals, values, and preferences to ensure that family conflict does not overshadow the patient’s voice. Recall that the goal is not to determine what the surrogates want, but rather to better understand the patient.
“I hear you proposing X. What would your brother say about that?”
“If your son were here with us, what would he say?”
Expect emotions. The patient’s illness and the conflict surrounding the decision may be emotionally distressing for SDMs and family members. Clinicians should acknowledge and help family members process those emotions (see Fast Fact #224). Avoid taking sides in family disagreements. When family members disagree, it may help to narrate the disagreement (e.g., “You seem to have different impressions of what your mom would say”). This can decrease the emotional tension. Demonstrate respect. Remember that loved ones are doing their best in a very stressful situation.
“I can see how much you all love your grandmother.”
“This is a strong family that fights for each other.”
Focus on values rather than positions. It can be tempting to focus on the choice that each stakeholder would like to implement. Instead, clinicians should focus on the values that lie behind each family member’s preference—for example, being a loving family member, ensuring the patient is treated fairly, or maintaining hope—and amplify those.
“I can tell you want to honor your grandfather’s will to live in whatever decision we make.”
“It’s clear that we need to make sure that your sister receives the best possible medical care.”
Allow adequate time. Loved ones will have numerous conversations on their own without the clinical team. Give them as much time as possible. Often it is easier to talk openly without clinicians present.
“Would it help if the clinicians step out so you can talk as a family?”
Build consensus based on shared interests and values. Clinicians should align with the values expressed by loved ones and, when possible, propose a course of action that incorporates as many of them as possible. Despite best efforts, sometimes a consensus between all family members just is not possible. In this case, decisions should be centered around the patient’s substituted judgment and what is medically appropriate when those can be reasonably discerned.
“While I’m hearing different perspectives on the best way to approach her care, it seems like the bottom line is that you all think it’s important to value her independence, safety, and comfort right now. Let’s work on a plan that does justice to those specific values.”
“I’m hearing that you have different opinions on the path forward. I think we should prioritize a care plan centered around what the patient would want and what is most medically prudent.”
When the Conflict Cannot Be Resolved
Consider a time-limited trial. A well-delineated time-limited trial with clearly defined outcomes may allow some family members to feel that their preferences are being honored while ensuring that those preferences have limits placed on them. See Fast Fact #401. Follow the primary SDM’s decision. If there is a single legally authorized SDM, clinicians ultimately may need to follow their decision. In such situations, the SDM may need additional emotional support from bearing the weight of medical decision-making. Clinicians should remind other loved ones of the surrogate’s authority. Often, the primary SDM will want consensus to promote future family peace: Acknowledge this and support the SDM’s decision-making if appropriate. When there are multiple SDMs with the same level of authority, obviously, this will not be feasible. Consult with ethics or risk management.
Footnotes
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.