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Deepshikha Charan Ashana, MD, MBA; Bryan Kibbe, PhD; Joseph Bertino, PhD
A 65-year-old man was diagnosed with extensive-stage small cell lung cancer with intracranial metastases. At the time of diagnosis, a chest CT also demonstrated subpleural and basilar reticular opacities with honeycombing, concerning for concomitant idiopathic pulmonary fibrosis (IPF). Subsequent imaging showed stable cancer and IPF after chemotherapy. He was subsequently admitted to the intensive care unit (ICU) with increasing hypoxia requiring oxygen supplementation via high-flow nasal cannula. Another CT revealed extensive ground-glass opacities. Treatment with empiric broad-spectrum antibiotics and high-dose prednisone was initiated for suspected IPF exacerbation, but he continued to deteriorate, ultimately requiring intubation and mechanical ventilation. Family meetings were held with the patient’s wife and son to discuss the challenge of dealing with two incurable and progressive diseases. The wife was distraught because she had believed his cancer was curable and had not been aware of the IPF diagnosis. However, she expressed hope for recovery and established a preference for continued restorative care with no limitations.
The patient’s son became increasingly angry that the finding of fibrosis had not been shared with them months ago when it had been discovered on the initial CT. He was belligerent during every encounter with the medical team, screaming profanities and racial epithets and mocking the physical attributes of some of the physicians. He even threatened to locate the attending physician’s home with the intent of harming him. After the son made this threat, a police report was filed and hospital security escorted him to the unit whenever he visited his father.
It became difficult to make clinical decisions because every conversation was derailed and prematurely terminated by the son’s behavior. The situation engendered tremendous fear and anxiety among the team, which made it challenging for clinicians to enter the patient’s room or synthesize objective data to create a plan of care. Eventually, the son was informed that he would not be allowed in the hospital unless he could behave in a civil manner. The team began to communicate exclusively with the patient’s wife, who made the difficult decision to withdraw life support after two weeks of mechanical ventilation with no sign of improvement.
What should be done when a surrogate decision-maker or a patient’s family or friends are hateful, threatening, and/ or disruptive in the hospital? When a patient is unable to make his/her own informed medical decisions, a legally authorized surrogate decision-maker is often essential to the healthcare decision-making process. Family and friends are frequently vital conduits for understanding a patient’s values and preferences. But making informed medical decisions that reflect a patient’s values and preferences is not the only ethical aim of modern healthcare. Hospitals are not merely vehicles for patientcentered decision-making; they are also places whose central obligation is to heal, comfort, and care for patients seeking medical attention. While it is important to make room for family, friends, and surrogate decision-makers at the patient’s bedside, there should be limits to what they are permitted to do, particularly when a family member crosses theline and threatens to harm a healthcare provider.
In pursuit of their mission to care for patients, healthcare providers voluntarily work in proximity to contagious and hazardous diseases that increase the degree of danger they experience in the workplace. However, healthcare providers’ willingness to assume some risk and danger is not boundless. Apart from the inescapable dangers involved in caring for patients with various diseases, disorders, and injuries, healthcare providers should firmly expect to work in an environment without the added risks of visitors to the hospital threatening to harm them. Connected to this commitment to a safe environment is the expectation of a respectful engagement wherein people are not demeaned, insulted, harassed, or bullied. Like the patients that they Exploring Ethics Readers are invited to submit cases that have led to ethical questions or conflicts, or those that caused moral distress. The Society of Critical Care Medicine Ethics Committee will solicit analyses authored by qualified ethics consultants with expertise in critical care environments. Through this process, we hope that readers will gain a better appreciation of ethical issues facing critical care clinicians, intensive care unit patients, and families or surrogates of critically ill and injured patients. We believe that readers will also develop a richer understanding of the role of healthcare ethics consultants and will become more comfortable using local ethics resources. How to Deal with Challenging Family Situations serve, healthcare providers should be treated respectfully as human beings.
In this case, the healthcare team took these ethical commitments to promote a safe and respectful environment seriously. When presented with a belligerent family member, screaming profanities and threatening to visit an attending physician’s home to cause harm, the healthcare team appropriately took some steps to reduce the threat of danger and to promote a more respectful discussion. The healthcare team filed a police report, had hospital security escort the patient’s son when he was in the hospital, and asked the son to behave in a civil manner. Other possible interventions might include consulting with the hospital ethics committee or others with experience in conflict resolution to mediate and facilitate discussions between the family and the healthcare team, limiting visiting hours for the belligerent family member, and restricting the visitor from entering the hospital.
In addition to safe and respectful environments, hospitals should be centrally oriented to the healing, comfort, mending, and care of patients. Often a patient’s family members and friends can be an important part of this process. However, a family member can also disrupt and be an impediment to the healthcare team’s efforts to care for the patient.
In this case, the son’s behavior prematurely ended conversations about aspects of clinical decision-making. The continuation of these conversations might have promoted the patient’s overall well-being. Instead, the premature end to conversations about clinical decisionmaking may have led to less-informed decisions or prevented decisions from being made, resulting in delays in providing timely medical care. Especially concerning is the way the son’s presence in the patient’s room provoked such fear and anxiety among the healthcare team that it made it challenging for them to enter the patient’s room to gather relevant data about the patient to inform the plan of care. The son’s behavior impeded the healthcare team’s ability to capably care for the patient and therefore challenged the team’s central ethical obligation to protect and promote the patient’s well-being through an informed decision-making process and the provision of expert medical care. Some responsive action was needed to better fulfill the healthcare team’s commitment to the patient over and above any commitment to the patient’s family member.
This case is unique in that a patient’s family member was not merely rude, angry, or disagreeable, but threatened to harm a healthcare provider and engaged in hateful, verbal abuse of healthcare providers. Restricting a family member from visiting a patient or being involved in the surrogate decision-making process is a serious and significant decision that deserves careful consideration but is one that is sometimes ethically supportable when the stakes are high enough. In this case, there were significant ethical concerns about maintaining a safe and respectful work environment for healthcare providers as well as protecting and promoting the patient’s care. Ultimately, in the interest of ensuring that individuals are treated fairly and consistently, hospitals ideally should develop a policy that outlines standardized procedures for responding to hateful, threatening, and/or disruptive behaviors of a patient’s surrogate decision-maker, family members, or friends.