Curi Advisory’s Janet McCrossen shares best practices for how medical care discussions should be handled when the wishes of patients and families are at odds.
Our Risk Solutions department will occasionally get calls from insured physicians requesting guidance on best practices for handling families arguing over medical care and decision-making with their family members. When families argue over medical care, doctors should take a structured approach to mediate conflicts while ensuring the patient’s interests and legal rights are upheld.
The key item to remember for physicians is that the patient’s wishes should always be prioritized over the family’s wishes. If the patient is capable of making decisions, their choices should take precedence. If the patient is incapable of making decisions, the physician should check to see if the patient has an advance directive (e.g., living will, healthcare proxy, PLST/MOLST form). If the patient has legally documented their preferences, those should guide medical decisions.
However, not all cases are so cut and dry.
When situations arise that place the healthcare provider in the middle of family dynamics, it is a good idea to bring all relevant family members together for an open discussion about the patient’s status. Clearly explain the patient’s condition, prognosis, and recommended medical interventions during these meetings.
If some family members accept the information while others resist, use a neutral mediator (social worker, palliative care specialist, etc.) to share updates on behalf of the care team. Encourage one family spokesperson to communicate decisions. If necessary, offer private discussions with individual members who struggle the most. Emphatic language to acknowledge grief while reinforcing medical realities should be used.
State laws may provide guidance on the hierarchy for decision-making when the patient cannot express their wishes, there is no advance directive, and when there are care disputes. Hospital policies, counsel, or an ethics committee can often provide guidance on ethical decision-making in these cases.
Informed consent state law can also protect healthcare providers when followed. Utilize an informed consent form or the care record to document the discussion. When a patient lacks capacity, has no advance directive, and no available family members or legally authorized representatives, physicians must follow an ethical decision-making process. Identify a surrogate if possible (close friends, caregivers, court-appointed guardians, etc).
If no surrogate or directive is found, the physician should determine what would be in the patient’s best interest. Consider quality of life, pain, prognosis, and standard of care. Involve a multidisciplinary team if possible (e.g., social workers, an ethics consult, or other physicians). Document thoroughly (capacity assessment, efforts to locate family/surrogate, review of directives, or lack thereof, rationale for decisions, involvement of ethics or legal entities, etc). State laws can help protect healthcare providers from providing care without informed consent so long as certain conditions are met; know the law in the state where you practice.
If treatment is futile, doctors are not obligated to provide it. State this clearly and compassionately. Example: “Continuing aggressive treatment will not change the outcome, and our focus should be on dignity and comfort.” Document conversations in the patient’s chart. Include the family’s concerns, your medical recommendations, and any agreements reached. If a family demands unnecessary treatment, hospital policy or legal intervention may be necessary to prevent harm.
If disagreements persist, an ethics committee can provide guidance on the best course of action.
If the patient’s wishes are clearly documented and legally valid, the physician MUST UPHOLD THEM, even if the family disagrees.
We encourage our insured providers to reach out to the Curi Risk Solutions team or Curi Claims team when these situations arise so we can help you make the best decisions.
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