How do you navigate conflicting patient preferences when family members disagree on the best care decisions?

One of the most important things to do is listen to the patient. If there are cognitive issues or not, please listen because you may hear the answer you need. If there are cognitive issues, the patient still has a voice. Provide two options, if possible, allows the patient to feel he/she can make a choice. Having worked with seniors and families for many years, have discussions about later in life care BEFORE you are in a health crisis. Make a list of what needs to be decided. Not a list of 50 things. Five to eight are plenty. Be sure to take time out so emotions do not overtake the discussions. Remember to give each other grace and patience.

First, ensure the patient’s wishes are prioritized, especially if they’ve expressed them directly or through an advance directive. Facilitate open communication among family members, helping them understand the patient's desires and medical realities. Engage in active listening to acknowledge concerns, and where possible, involve an impartial mediator like a social worker or ethics committee to guide discussions. It's essential to keep the focus on the patient’s best interests while respecting family input and emotional needs.

Expanding on this, it’s important to facilitate open communication between the family and the healthcare team. Hosting a family meeting can be an effective way to address concerns and ensure that everyone understands the patient’s condition, the proposed care plan, and the legal framework governing decision-making. During these meetings, it’s beneficial to have a neutral mediator, such as a social worker or patient advocate, who can guide the discussion constructively and help manage conflicts if they arise. Additionally, providing educational resources to the family about the patient’s condition and possible treatments can also aid in reducing misunderstandings and aligning expectations.

To build on this, employing structured communication techniques can greatly enhance the effectiveness of these discussions. Tools such as the “I statement” framework encourage individuals to speak from their own perspective without placing blame, which can reduce defensiveness and foster a more open dialogue. For example, saying “I feel worried when we discuss treatment options without clear outcomes” instead of “You don’t care about the risks” can help keep the conversation constructive. Additionally, setting clear rules for engagement at the beginning of the meeting—such as one person speaking at a time, no interruptions, and respecting each person’s speaking time—can help maintain order and respect throughout the discussion.

Listen to the patient and to each other. Be empathetic. Put yourself in their position. Think about how it will look if you were being discussed. Your needs were being talked about as if you weren’t even there. Rome wasn’t built in a day and remember to deal with these serious and stressful situations in small doses. I recommend to have someone available who is NOT emotionally vested in the family and is skilled at the subject matter. This person can listen, offer suggestions, answer questions and be a resource. We all have strengths and weaknesses so try to give each person a part to play to help support the patient. Something the person can easily handle. Know when to say “No, this is not something I can do.” That is OK.

It’s essential to regularly reassess the patient’s capacity, as it can fluctuate, especially in cases involving mental health issues, neurological conditions, or the effects of medication. These reassessments should be conducted by qualified professionals such as neurologists, psychiatrists, or geriatric specialists, depending on the patient’s underlying condition. Involving an ethics committee can also be beneficial if there are ongoing disputes or complex issues concerning the patient’s values and the interpretation of their prior wishes. An ethics consultation can provide a balanced view that considers both medical and moral aspects, helping to guide the proxy and the healthcare team in making decisions that honor the patient’s autonomy

Further enhancing this approach, consider utilizing decision aids such as brochures, videos, or interactive tools that clearly outline treatment options and their potential outcomes. These aids can help demystify complex medical information, making it more accessible and easier for family members to understand and discuss. Additionally, it might be beneficial to involve a patient navigator or care coordinator who specializes in guiding patients and their families through treatment choices and healthcare systems. This professional can provide personalized assistance, helping to explore all possible options, including those that may not be well known, such as experimental treatments or newly approved therapies.

To effectively uphold the patient’s expressed wishes, it’s also crucial to educate the family on the importance and legal standing of advance directives and living wills. Providing clear explanations about how these documents are meant to function and their role in medical ethics can help align the family’s expectations with the patient’s autonomy. Additionally, consider facilitating a meeting with a healthcare ethicist or a legal advisor if there’s significant resistance or misunderstanding about following these directives. Such professionals can offer authoritative insights and mediate discussions, helping to clarify the ethical and legal implications of honoring the patient’s wishes.

I have a personal story on this one. I found that when I was delivering my baby, I preferred not having visitors. The doctor and then the hospital had procedures in place to accommodate this even when there was a lot of pushback from other immediate family members.