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Case

Ms. T, in her late 60s, was diagnosed lung cancer, and which had spread to her brain, bone, liver, and lymph nodes. She was initially hospitalized for recurrent sepsis (an infection causing damage to tissue and organs), respiratory failure, and disease progression. Her condition worsened, requiring a visit to the Intensive Care Unit (ICU) for three days. Her hospital course of stay included complications due to worsening septic shock, and internal bleeding. Ms. T lost capacity, but had previously appointed her daughter as her designated Medical Power of Attorney (MPoA).

The family, specifically Ms. T’s daughter (a medical provider at another health system), requested full resuscitative efforts should her mother suffer any respiratory failure. Despite knowing the poor prognosis, the daughter communicated with the team that she wanted to make sure she had done everything for her mother. She declined palliative care service, as for her, it signified giving up and her goal was to get her mother back home.

Although the care team respected the family’s wishes, the patient continued to decline, and the daughter started to insist on specific dosages of medication, oftentimes refusing medications she believed not to be in the best interest of her mother. For the care team it became difficult to manage the care of the patient and called for an ethics consult.

The Ethical Issue

This case raises the ethical issue of duty to care, with an emphasis on dual-role conflicts. This case investigates what boundaries exist for a patient’s MPoA who also happens to be a healthcare professional.

Healthcare professionals as family caregivers walk a fine line between their dual identities as a caring family member and healthcare provider. At times, these two roles and their various responsibilities can be at odds (1). Healthcare providers who care for family members may struggle to separate the two identities and what each role requires (2). In a prior study, a physician reported having trouble disassociating between being a caregiver for a family member and having medical knowledge. In another study, a nurse described how having medical knowledge can increase stress because they are aware of the various outcomes, cure, palliation, or death. Another study reported nurses feeling guilty because they were not attentive to a clinical change in their loved one’s condition (3). Healthcare professionals may struggle with anxiety and feelings of providing inadequate care due to the knowledge they hold and responsibility that they may feel to look after members in their family or personal community.

Discussion

It is not uncommon that an individual with a background in healthcare be appointed as a friend or relative’s MPoA. Decision-making on behalf of an incapacitated patient involves adequate communication between healthcare staff and the decision-maker. Communication pertaining to these subject matters may thus be easier when the decision-maker is already familiar with medical terminology.

Decision-making on behalf of another individual is guided by substituted judgment or the best interest standard. Substituted judgment occurs when the decision-maker knows the patient’s preferences and thus makes the decision that the patient would have made themselves (4). By contrast, the best interest standard is implemented when patient preferences are unknown. In that situation, the decision-maker must make decisions with consideration of promoting patient welfare, i.e., focusing on relief of suffering, preservation or restoration of function, and the extent and sustained quality of life that a reasonable individual would choose in similar circumstances (4).

In both models, a physician must disclose the nature of the therapy, purpose, risks and consequences, benefits, probability of success, feasible alternatives, and prognosis if there is no intervention. A physician should also provide a recommendation to uphold the process of shared decision-making (5). In general, the responsibilities of a physician in the care of a patient are to attend to a patient’s needs with allegiance and to uphold the principles of autonomy and social justice (4,6). Allegiance is a commitment to a cause, community, or individual. Physicians will have multiple allegiances, whether it is to their patient, their community, their family, a foundation, etc. However, when these allegiances conflict with the duties that shape medical professionalism, a choice must be made (4). These tensions can generate a dual-role conflict.

A dual-role conflict occurs when an individual has competing motivations that affect decision-making. These conflicts can be unethical when an individual goes against the responsibilities entrusted to them to act upon an opportunity for personal benefit. An unethical dual-role conflict undermines the integrity of the roles or responsibilities of an individual or organization. Ms. T’s daughter has a dual-role conflict in caring for her mother as a healthcare professional. A dual-role conflict is not always an ethical issue and sometimes must simply be acknowledged. Unfortunately, Ms. T’s daughter’s involvement became an ethical issue when she failed to stay within the boundaries of the role of a MPoA. She used her background as a healthcare professional to undermine the healthcare team and disrupt the medical care provided to her mother. Distinguishing the roles and responsibilities of all parties involved in the decision-making process can help mitigate concerns surrounding the ethical issue of duty to care with emphasis on a dual-role conflict.

Recommendations

We offer three recommendations to healthcare teams that find themselves in similar situations. The first is to legitimize the multifaceted identity that the decision-maker holds. While the MPoA in this case is the daughter of the patient, she is also a healthcare provider. An individual’s identity is not solely comprised of familial relationships but also by career, experiences, social identity, religion, etc. (7). Acknowledging aspects that form the individual’s identity and influence decision-making may build trust and rapport between the care team and decision-maker, potentially aiding in establish cordial discussion.

Next, we recommend identifying the similarities and differences between the responsibilities of a MPoA and those of a primary physician. Doing so shows that both the decision-maker and patient’s primary physician are focused on providing the best care for the patient. Identifying these differences can aid in relieving feelings of anxiety and burden of providing adequate care felt by the decision-maker.

Lastly, we recommend reinforcing the role and responsibilities of the decision-maker. MPoAs who are also healthcare professionals may feel a sense of heightened responsibility due to the patient’s trust in their expertise. Individuals in this position may feel the need to control care out of fear of letting the patient down or making a poor decision. Reiterating the responsibilities of a MPoA can help empower these individuals to maintain a sense of control while still respecting the boundaries of their authority when it comes to decision making.

Case Study Questions

  1. How can healthcare teams manage situations where a medically-trained family member, in the same specialty, attempts to influence clinical care/decisions?

  2. What role does clinical ethics play in mediating emotionally intense conflicts between families and healthcare teams, and how can it support both parties?

  3. How would you handle the above case if Ms. T had capacity to make decisions?