Decision making

Treatment requests contradict patient wishes

I know he didn't want to be fed but he's starving to death. I just want to give him a little something so he knows I'm here. ~ Family member

On occasion, the family or the substitute decision-maker has wishes contrary to those documented by the patient. Initially, your task is to gain family agreement to talk with you. This informal consent is critical, or the family may continue to resist your efforts and see you as a threat instead of an ally.

This type of situation will require your patience and calm presence. Acknowledge that these decisions are difficult and emotional, and allow time for discussion.

Considerations

  • Is the patient able and willing to participate in a discussion with family?
  • What do your community guidelines say about involving other health care providers?
  • What are/were the patient’s goals of care?
  • How clear are/were the patient’s goals?
  • Are the family’s requests consistent with the goals of care?
  • What will be the likely outcome if family requests are met?
  • Will meeting these requests provide quality end-of-life care?
  • How can the patient’s wishes best be respected?


Conversation Prompts

I’m here to work with you. The first thing we need to do is make sure you're fully aware of what’s going on. Could we have that conversation? 

(When you feel you have a firm enough connection with the family, you can continue:) 

I know this is difficult to accept, but things are much more serious than you may realize. I want to help you by being completely honest. I know this is going to be very hard to hear. He’s critically ill.

(Pause) 

We’re far beyond the point of being able to save him. I think it’s very likely he’ll die shortly. Can I explain the options? An aggressive medical intervention is not what’s needed now.

***

I know this is hard. Your husband made a decision a few months ago about his care but now you’re wondering what would be best. Let’s take some time to talk about his wishes and your concerns so that we can find a way to honour his wishes together. 

***

It’s difficult when you feel that you have to make these decisions on your own, without being able to speak with your wife. But remember that she took care to plan for this possibility and left instructions so that you could know that you were following her wishes.