3
Using Ethical Decision Making and Communication Skills to Minimize Conflict
DOUGLAS HOUGHTON
LEARNING OBJECTIVES AND OUTCOMES
Upon completion of this chapter, the reader will be able to:
Understand the types of health care decisions faced by patients/families
Describe several types of advance care planning and documentation
Understand the role of the surrogate decision maker in health care settings
Describe the role of cultural background on the communication and decision-making processes
Describe important components of the communication process between the health care team and patients/surrogates
Understand the role of the nurse in the communication and decision-making processes in health care situations
Describe key elements of the goals-of-care conference
Discuss strategies to minimize conflict in the health care decision-making process
DECISION MAKING AND HEALTH CARE
As RNs, we know that health care consumers (i.e., our patients) often face some of the most challenging decision situations imaginable. These decisions are challenging due to the often serious consequences of these decisions; it is not an exaggeration to state that life or death may be in the balance. These decisions may be made for oneself or for loved ones while serving as their surrogate, and may need to be made based on information given by a health care provider (HCP) they do not know well, if at all. The health issues at stake and prognoses given may be difficult to understand clearly for decision makers without health care experience. Additionally, in the inpatient environment these critical decisions are frequently made at a time of emotional distress, exhaustion, uncertainty, and fear. Communication between the patient/family and health care team may be limited or nonexistent, misunderstood, or fail to address prognosis and meaningful goals of care. Consequently, conflict is a common occurrence between involved parties in health care decisions (Kayser, 2014). This conflict may arise between HCPs and families, HCPs and patients, patients and families, or within families themselves. Fortunately, knowledge of available evidence from pertinent research, strong communication skills, and a sound ethical decision-making framework can minimize such conflict. RNs need a strong set of communication and conflict resolution skills and an understanding of the multiple factors that may influence the health care decision-making process, so that they may provide expert guidance to support patients and families during this often-complex process. These skills are an essential Quality and Safety Education for Nurses (QSEN) competency.
CASE SCENARIO
AJ is a 22-year-old male, whose family has recently located to south Florida from Colombia. AJ has had a high-speed motorcycle crash and sustained life-threatening injuries, including multiple rib fractures, a pelvic fracture, and a severe traumatic brain injury (TBI). He had difficulty breathing at the scene and was endotracheally intubated by paramedics en route, but only after much difficulty during which he experienced a 5-minute hypoxic period. He arrived at the trauma center with a Glasgow Coma Score (GCS) of 3. He is admitted to the intensive care unit with respiratory distress, anemia related to bleeding from his pelvic fracture, and altered mental status from his TBI. His primary nurse is Kevin, a Caucasian male from upstate New York. Kevin has 10 years of experience as an RN in critical care, and 5 years in his current position. Kevin is keenly aware of the long and complicated hospital course that AJ will likely experience.
Importance and Types of Decisions in Health Care
Most everyday treatment decisions in health care in the United States are made collaboratively between mentally competent patients and providers. Whether or not to start a new medication for a chronic illness, undergo recommended routine screening exams, and how to execute a plan to quit smoking are common scenarios in routine outpatient care which elicit minimal drama and contain little or no ethical content. However, health care decisions become much more complicated in the acute care or inpatient setting. These decisions may involve life and death, comfort or pain, and may require patients, families, and providers to make end-of-life care decisions they are not prepared to face. There is often little or no relationship between the patient and these HCPs, and there is the added stress of an acute illness and hospitalization. The illness or injury leading to the hospitalization may have been unexpected, or it may be an exacerbation of a chronic health condition. Guiding patients and decision makers through end-of-life care choices poses a particularly significant and complex problem often faced by nurses. In spite of significant national efforts by the health care community to improve end-of-life care, a recent study showed that patient/surrogate reports of pain, depression, confusion, and other symptoms actually increased during the time period from 1998 to 2010 (Singer et al., 2015).
Unfortunately, many older persons and even those with chronic illnesses fail to clarify the kind of care they would prefer in the event they become unable to decide for themselves. Only about one quarter of the U.S. adult population has some type of advance directive describing what kind of care they would like at the end of life. This number approaches 50% in senior populations, but this leaves a vast number of Americans without clearly described wishes should a health crisis arise (Institute of Medicine, 2014). These numbers demonstrate that a great deal of ambiguity often exists for those left to decide among care options for incapacitated loved ones. The advance care planning process can eliminate or ease the concerns of health care surrogates and HCPs and help ensure that care provided is consistent with patient values and wishes. Nurses can play a key role in educating the public and their own patients about available options, and encouraging them to complete some type of advance directive. See Box 3.1 for a description of advance care planning options.
Questions to Consider Before Reading On
1. Do you have an advance directive stating the kind of care you would prefer? How about your loved ones?
2. How would you assist a patient/family in understanding the advance care planning options presented in Box 3.1?
Influencing Factors in Health Care Decision Making
Many factors influence the decision-making process, including personal values and culture (of both the provider and the patient/family), level of education, religion, prognostic (un)certainty, and patient/family trust in the HCP (Institute of Medicine, 2014; Philipsen, Murray, Wood, Bell-Hawkins, & Setlow, 2013). The influence of culture is pervasive, and providers must often listen diligently in order to hear and understand cultural nuances in communication and decision-making styles (Pascual & Marks, 2014). Race and religion have been demonstrated to have a significant effect on illness perception by patients and families, which may result in a situational “perception gap” between patient/families and providers (Ford, Zapka, Gebregziabher, Yang, Sterba, 2010). Cultural background has been found to influence end-of-life care costs, with Black and Hispanic groups choosing more aggressive support and costly care near the end of life (Hanchate, Kronman, Young-Xu, Ash, Emanuel, 2009; Institute of Medicine, 2014; Johnson et al., 2010). Level of religiosity has also been identified as a predictor of more aggressive life support choices (Pew Research Center, 2013; Phelps et al., 2009). Caution must be used when applying such research data to individual situations, since wide variations exist within cultural groups. Nurses must also be aware of the effect of their own cultural background on their values, decision styles, and communication styles. This is particularly relevant in the United States, a country with significant cultural diversity. Some groups may reflect blending of cultural norms through assimilation (“hyphenated” groups, such as African American, Irish American, Italian American), while others remain largely true to their culture of origin (Purnell, 2012).
Box 3.1
Advance Care Planning Options
Definition of advance care planning: A process of ongoing discussions regarding one’s wishes for future medical care, particularly end-of-life care. Participants may include individual patients, families or support systems, HCPs, and legal representatives.
Advance directives: Patient-initiated documents that describe future care wishes or name a health care surrogate should the patient be incapacitated. These include:
Living will: a document describing care preferences should the patient be medically determined to be in terminal condition.
Durable power of attorney for health care: written legal designation of a person named by the patient to make health care decisions for the patient should he or she be incapacitated.
Medical orders: Order sets created and signed with a physician or other HCP governing emergency, inpatient, and/or end-of-life care for a seriously ill person. These may include:
Physician orders for life-sustaining treatment (POLST): medical orders covering a range of care topics common in serious or terminal illness, to designed to cross-care settings. Appropriate for frail or terminally ill persons, binding in many states (www.polst.org).
Do-not-resuscitate, allow natural death, do-not-hospitalize, do-not-intubate: medical orders written to apply in a given health care setting governing end-of-life care.
Adapted from Institute of Medicine (2014).
Communication Styles
Communication is an essential part of the decision-making process. It is vital that necessary information such as prognosis is communicated from the health care team to the patient/surrogate, and equally important that the patient/surrogate communicate patient preferences, values, and questions to the team. Culture influences how we prefer to receive and transmit information to others, and significant conflict can result if communication (HCP–patient–surrogate) is not effective. Awareness of our own communication style and how it may differ from that of the patient/surrogate is key to providing culturally sensitive and high-quality health care in a multicultural society such as the United States (Purnell, 2012). In U.S. and Western European cultures (predominantly individualistic cultures), communication styles are more direct, with eye contact being common and a sign of attention. In collectivistic cultures such as Japan, India, and many Latin cultures, communication may be less direct and contain significant nonverbal cues (Giri, 2006). Nurses providing care to persons of cultures other than their own are encouraged to become familiar with cultural variances, particularly with regard to health beliefs, end-of-life beliefs and practices, and communication styles.
Decision-Making Styles
As with communication style, culture also has a profound influence on how patients/surrogates make decisions. Collectivist-oriented cultures place more value on the social impact of situations, and may undertake the decision process as a family group instead of as individual members making autonomous decisions. Family conferences may include a large number of participants, which may be intimidating for some clinicians. The patient/surrogate may consult clergy members to participate and offer opinions in the decision-making process.
In contrast, predominantly individualist cultures like the United States emphasize personal responsibility for decision making, and for the consequences of the decision process. Gathering information through asking questions and an active, assertive decision process and conflict resolution style is the norm. Individual patients/surrogates who are not accustomed to the predominantly direct, decisive communication and decision-making style of U.S. HCPs may find it difficult to communicate health care preferences and decisions in this fashion (Guess, 2004; Purnell, 2012; Ting-Toomey & Chung, 2011).
Questions to Consider Before Reading On
1. Have you or a peer experienced a patient/family care situation in which culture (either your own or that of the patient/family) may have influenced the communication/decision-making process?
2. How could cultural awareness and competence improve this process in the future?
CASE SCENARIO (CONTINUED)
AJ’s family arrives at the trauma center. They are brought to the intensive care unit to see AJ for the first time. His family consists of his mother, 52, his father, 54, two younger sisters ages 12 and 14, and an uncle (his father’s brother). They speak only Spanish, as they have been in the country for only 6 months. AJ’s parents do not allow his sisters to see him, as they are afraid they may be overwhelmed and faint. His father, mother, and uncle proceed to the bedside. They are shocked by the sight of AJ, whose body is swollen and has multiple severe skin abrasions and lacerations.
AJ’s family is greeted by Kevin, his nurse. Kevin speaks some Spanish and he is able to communicate basic information to the family. AJ’s mother is very emotional, crying, and unable to focus well on what Kevin is telling them. Kevin, knowing that many health care decisions will need to be made for AJ, calls both AJ’s primary physician, Dr. B, and the unit social worker in order to arrange an informational meeting and to complete paperwork to designate AJ’s mother or father to serve as his health care surrogate (or proxy) while he is incapacitated. Kevin also calls for professional interpreter assistance, knowing that the family speaks little English.
The Role of the Surrogate in Decision Making
In Western society, the ethical principle of autonomy has come to dominate the health care decision-making process. The right of the patients to decide for themselves is supported by significant medical-legal precedent cases, which include support for decisions made by health care surrogates on behalf of incapacitated patients, in accordance with state laws (Wolf, Berlinger, & Jennings, 2015). Recent data show that more than 40% of older hospitalized patients are unable to make their own informed choices about health care options due to acute or chronic illness–related reasons and require involvement of a surrogate; 23% were completely reliant upon a surrogate decision maker (Torke et al., 2014). As described previously, many people fail to actively participate in the advance care planning process, leaving surrogate decision makers without clear guidance as to what type or level of care the individual would prefer in a health care situation, should they be unable to decide for themselves. Conversely, the events leading to a health care crisis may have been unanticipated, as in the case of a young trauma victim who had been previously in good health. Nurses in an inpatient environment will frequently be working with and supporting surrogate decision makers, which serves to protect the patient’s autonomy.
From an ethical perspective, the surrogate has a duty to act in accordance with the patient’s preferences and values, if such had been expressed verbally or in writing. The primary ethical principle guiding decision making is autonomy, although the principles of caring and beneficence are also applicable to the surrogate decision-making process. Many health care surrogates struggle in their role due to multiple emotional and cognitive factors, leading to profound distress. Surrogates who have no prior experience in the role, as well as those who had not engaged in prior discussions with the patient about their treatment preferences, have reported increased stress and decreased confidence in their ability to act for the patient (Majesko, Hong, Weissfeld, & White, 2012). Nurses can improve and support the decision-making process of surrogates by educating them on their role, emphasizing that all decisions made should reflect the patients’ wishes and values and how they would likely decide for themselves if they were able to do so (the legal concept of “substituted judgment”). Should surrogates have no direct knowledge of patients or their values prior to their incapacity, the standard for decision making is “best interest,” which requires that surrogates decide (in their judgment) what decision or course of treatment would be in the best interest of patients. This triad (HCP–surrogate–patient) complicates the decision-making process, in addition to the fact that patients who require surrogates are sicker, have more in-hospital transfers, and more often die when compared to patients who do not require surrogates (Torke et al., 2014).
Questions to Consider Before Reading On
1. Who would serve as AJ’s surrogate decision maker if his parents were unavailable?
2. As the nurse caring for AJ, how should Kevin assist this surrogate to understand his or her role?
The Role of the Health Care Provider in Decision Making
HCPs, most commonly physicians, are the primary source of medical information regarding patient condition and prognosis for recovery. This role may also be filled or supplemented by a nurse practitioner or physician assistant. The communication of this information in a respectful, complete, and understandable manner is essential to an ethical decision-making process reflecting virtue, caring, and beneficence. Establishing a trusting relationship and making time to elicit patient values are critical, especially in situations where end-of-life choices are needed (Cook & Rocker, 2014; Kayser, 2014). An important nursing role is to ensure that the communication process is taking place, identify any anticipated problems, and help clarify care options with patients, families, and surrogates.
Provider decision-making behaviors can be described in four common roles:
Informative (HCP provides information only, no guidance.)
Facilitative (HCP provides information, elicits patient preferences, and guides the surrogate in his or her decision-making process to apply these preferences.)
Collaborative (HCP provides information, elicits patient preferences, provides surrogate guidance, and makes a recommendation.) This may also be described as a shared decision-making model, which is most often recommended by professional guidelines, societies, and available evidence.
Directive, or paternal (HCP makes a decision without patient/surrogate consultation.) This is less often recommended but may be appropriate for some situations such as emergencies or routine medical care (Cook & Rocker, 2014; Manara, 2015; Uy, White, Mohan, Arnold, & Barnato, 2013).
A recent U.S. study of physicians’ decision-making roles in a simulated intensive care unit scenario identified 1% as informative, 49% were facilitative, 37% were collaborative, and 12% used a directive role (Uy, White, Mohan, Arnold, & Barnato, 2013). Another large survey of critical care physicians found that the vast majority of critical care physicians feel comfortable making life support recommendations (92%) and believe it is appropriate for them to do so (93%); however, only 22% reported always doing so (Brush, Rasinski, Hall, & Alexander, 2012). Debate continues in medical literature regarding the role of the physician and his or her responsibility to make treatment recommendations to patients/surrogates (Hutchinson, 2015; Veatch, 2015), although a shared decision-making model is recommended by the Society for Critical Care Medicine and the American Association of Critical Care Nurses, among others. A recent joint policy statement from multiple medical and nursing organizations explicitly states that “it is ethically untenable to give complete authority for treatment decisions to either patient/surrogates or individual clinicians. Instead, clinicians and patient/surrogates should work collaboratively to make treatment decisions” (Bosslet, 2015).
An important part of the role of nurses in patient/family discussions is to identify their own values and biases, and make every attempt to distance their own views from the expressed wishes of the patient, should there be any. The acknowledgment and setting aside of one’s own biases and values reflect an understanding of the ethical concept of nonmaleficence. Cultural and personal values may conflict with those of the patient/surrogate, leading to moral distress on the part of the nurse and other providers when they are asked to provide care they believe is inappropriate, burdensome, or nonbeneficial to the patient (Keyser, 2014; Pascual & Marks, 2014).
CASE SCENARIO (CONTINUED)
Kevin, Dr. B, the social worker, an interpreter, and AJ’s mother, father, and uncle meet in the unit conference room. Dr. B, through the interpreter, describes AJ’s prognosis, multiple injuries, and what needs to be done at present. The prognosis for functional recovery is very poor, because of anoxic brain damage from the prolonged period when AJ was not able to breathe well. His other injuries are severe but likely survivable in a young healthy person. His pelvic fracture would need surgical repair, but because of AJ’s poor neurological prognosis, Dr. B recommends not doing the surgery. He explains that this is because AJ will not walk due to his brain damage and the surgery would be extensive and has risks. AJ’s family appears overwhelmed and tearful, and his mother is repeating prayers aloud in Spanish through her tears. Kevin provides emotional support. Dr. B, knowing that the family will need time to process the prognosis, says he must leave but schedules another meeting in 2 days. The family asks if they may bring other family members to the next meeting, and the team agrees to the request.
Question to Consider Before Reading On
1. Have you or a peer experienced a patient/family care situation in which you disagreed with a treatment decision because you believed it to be inappropriate, burdensome, or nonbeneficial? What was the outcome? What were your feelings?
The Role of the Nurse in the Decision-Making Process
The nurse plays a vital role in the health care decision-making process, since he or she is often the most visible and present member of the health care team, especially in the inpatient environment. Families often ask the nurse for his or her opinion when weighing care decisions, and informal, honest dialogue about the patient situation may help patients/surrogates clarify priorities and goals of care. Through application of the ethical concepts of virtue, caring, and beneficence, the RN can play a valuable role in helping patients/surrogates to understand their choices and the ramifications of various options. The nurse can also support the patient/surrogate emotionally, advocate for them, and help them formulate questions and understand the choices they are facing. This is especially important when the patient/surrogate is of a different cultural background than the primary HCP responsible for the patient’s care. These actions are supported by the American Nurses Association’s (ANA) Code of Ethics (2015), Provision One, which states, “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person” (p. 1).
Guides to Inform Ethical Decision Making
James Rest’s four-component model (FCM; 1986), described in Chapter 2, and the framework for ethical decision making utilized in this book offer assistance to nurses seeking to provide guidance through the decision-making process for patients/surrogates and families. See Tables 3.1 and 3.2 for application of these models to the Case Scenario presented here.
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