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Ask an Expert: What if there is no advance directive and family members disagree about treatment?


What should a hospital do when a patient does not have an advance directive and the family members disagree about what should medically be done for their loved one? For example, would the family members be encouraged to participate in mediation? What would PeaceHealth suggest?

This is a complex question, so I got opinions from two people that work at SHMC and are knowledgeable on this topic.

This from Dan Reece MSW who at the time I asked was the director for Social Work at Sacred Heart:

“It is not unusual for family members to disagree on medical decisions when the patient does not have an Advanced Directive, or even more importantly, when the patient has not discussed their feelings and beliefs with them. Physicians and SHMC staff, including social workers and chaplains, are available to assist families in coming to agreement. In addition, the SHMC Bioethics Committee is available on request to consult with both the family and the professional medical caregivers. The Bioethics Committee is not a decision-making body, but it can help the parties develop an ethical framework for making decisions.”

In cases where agreement cannot be reached, there is a legal hierarchy of family decision-makers.

. . . and this from Bob Scheri of pastoral care services at Sacred heart.

“Dan’s response is very good. Ultimately, the question family members must ask is not “what do we/I think should be done for my family member?” From an ethical perspective the better question is, “what would my family member want done if he/she could speak for themselves?” The answer to this question is more often than not, quite different from the answers given to the first question. This question often prompts a shift in thinking among family members. Conflict is still present, but the focus is on one person’s values and feelings: the patient. As Dan stated, we have a variety of resources and supports available to families in such a conflict to think through the issues and discover the most helpful questions. Our goal would be to assist families in moving towards understanding and ultimate agreement. Within this process there is another key question that must be addressed: Who is the decision maker? Obviously, the patient is, but when the patient can no longer speak for themselves, who will voice or be the spokesperson for the patient’s wishes? Ultimately, the law outlines who this would be without an advance directive. This person would be responsible in the end to reach a conclusion and make a decision consistent with the patient’s values. While we prefer that we succeed in helping families come together, having clarity on who the legal decision maker is provides an ultimate framework for decision making. This also helps families in extreme conflict to realize that there is a legal framework within which they must work.”

What would PeaceHealth suggest? That the caregivers first clarify the question about who the ultimate decision maker is, and second to facilitate discussion about what the patient’s wishes would be given the medical condition and prognosis. If conflict proves to be an obstacle, call a chaplain, social worker or request support from the ethics committee.

Answered by Tom Ewing, MD, Family Practice, Eugene, PHMG/Admin-Willamette

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