While working an ER shift, I saw a 55-year-old female present with back pain with a previous history of breast cancer. After imaging and tests, it was concluded that her breast cancer had returned, but this time, with metastasis to the spine.
It was a heart-wrenching case, and although treatment options were available, I knew her oncology team was in for a very tough discussion.
I hate talking about cancer with my patients, especially because I am not an oncologist, so I don’t have a concrete bank of knowledge about specific treatment options. However, this woman understood that I was an ER doctor—not an oncologist—but her family members who were present wanted answers.
A fine balancing act
They wanted to know how soon she could start treatment, what her treatment options were, and the success rates of these treatment options. I had to explain that without a tissue biopsy and a team of oncologists by my side, I could not answer these questions.
Emotions were running high, as expected. Then the patient told me privately that she did not want to fight this anymore, and she knew this decision would upset her family.
She chose to go home and follow up with her oncologist in the morning. I knew her oncologist, so I put in a consult and mentioned what she had told me in the notes. I wanted the oncologist to be aware of the family dynamic going into the case.
"Although we are primarily treating our patients, we are also indirectly treating their family members."
— Kristen Fuller, MD
Patient autonomy is one of the most important aspects of patient care. Still, patients often don’t make decisions about their medical care alone, especially regarding critical care, oncology, or end-of-life care. Sometimes, their family’s desires supersede their own.
Sometimes, family members can be manipulative, controlling, and have ulterior motives, and we, as physicians, need to recognize these incidences and protect our patients. We owe it to them to provide the care they want and deserve, while also considering their loved ones' input.
Get to know the patient’s family
You may feel that your patient trusts you, but their family members are still at odds with the treatment options. Just as it takes time to establish a trusting relationship with your patient, it also takes time to establish this relationship with their family members.
This may mean that you have multiple conversations with the patient’s family and hold family meetings to establish trust.
Prior to sharing your patient’s diagnosis and treatment plan with family members, ask your patient which pieces of medical information they want to share, and which they don’t.
Devise a plan for how your patient wants this information delivered to their loved ones. Do they want to tell them; do they want your help telling them; or do they want you, the physician, to tell them on your own?
Document your conversations in the patient’s chart
Oftentimes, there are many consultants on the case, especially if it is a critical care or trauma patient, and many of these consultants will not be as familiar with the family dynamic.
It is important to objectively document any family meetings or conversations so other physicians can understand what is happening and there is no confusion between medical teams.
Help them to identify their values
Patients and their family members often share the same morals and values, so facilitating a discussion about goals can help get everyone on the same page. Values can include what to do in end-of-life care, how to minimize suffering, and goals regarding quality of life.
The goal is to find shared values among the patients and their family members so they can come together and respect each other's perspectives.
Other hospital staff can help
In critical care situations, when patients cannot make decisions for themselves, there is often a power of attorney or surrogate decision-maker—this is often a family member. However, this person may not be making the best decision for the patient, may be at odds with family members about patient care, or may be unable to decide on your patient’s care because they are too emotional.
This often happens in ICU or trauma settings. Sometimes, enlisting the help of a chaplain, a social worker, or the hospital ethics committee can help mitigate tension and create consensus.
The hospital ethics committee is especially important when you believe there is no quality of life for the patient and the family continues to insist on aggressive care such as CPR, mechanical ventilation, and dialysis, instead of focusing on comfort measures.
When tensions are high, remember that you can call on these other hospital staff members to help. Like you, many have received training on how to help moderate and balance patient wishes with those of their loved ones’.
Each week in our "Real Talk" series, mental health advocate Kristen Fuller, MD, shares straight talk about situations that affect the mental and emotional health of today's healthcare providers. Each column offers key insights to help you navigate these challenging experiences. We invite you to submit a topic you'd like to see covered.