Learning from lingering angst.

I am leading a debriefing session--the second part of a three-part model we have started for ethics consultations at our rehabilitation hospital. The debriefing is loosely organized. We begin with follow-up from a recent ethics consultation. For some team members, this is a time to learn how ethics was involved and how things got resolved. I then ask for their responses to the case: what went right, what went wrong. One team member remarks, "I was angry at Maria's daughter. She never let anyone get a word in edgewise, including her mother." Another says, "I was emotionally exhausted. Her daughter was manipulative. She was good at splitting the team and playing us against each other." Respecting the patient's autonomy was impossible, one notes, because she was never allowed to interact independently with her care team. Another responds that he felt frustrated that the patient never asked her daughter to step out of the room. Several say that when they asked the daughter to leave, she refused. Some report avoiding the patient except when they had to treat her. Based on what they saw, some team members think that the whole family mistrusted the health care system and that the daughter probably felt that she was advocating for her vulnerable mother. But all feel that she took this stance too far--that she had crossed boundaries inappropriately and was angry and accusatory with the staff. As the facilitator, I try to strike a balance. The debriefing has the potential to devolve into a complaint session. It can also focus on an answer that is too simple. I encourage a range of opinions and gently challenge some assumptions. There are few formal spaces for dealing with the emotional aspects of difficult cases, especially as a group of multidisciplinary professionals who have collectively cared for a patient. The typical cases that come to our ethics consultation service are about decisional capacity, surrogate decision-making, safety, goals of treatment, and, less frequently, about withholding or withdrawal of treatment. Not every case needs all three parts of the model: a consultation, a debriefing, and an educational seminar. The ones that benefit most from a debriefing are the ones that linger with staff--those that leave them disagreeing with each other or feeling like they didn't do "right" by themselves or their professions. This is especially true when the case is as fraught as this one was. Maria was a seventy-year-old woman who had had a stroke, and decisions needed to be made about her discharge and her ongoing care needs. Maria had two children: a son, Darryl, and a daughter, Lee Ann. Each was equally able to serve as her surrogate under the applicable surrogate law. The problem was that Darryl and Lee Ann disagreed with each other about all aspects of their mother's care. And, complicating things further, Maria tended to agree with whichever of her children was present in her room. As became apparent in the debriefing, Lee Ann's behavior was especially grating to Maria's health care team. Whenever the psychologist, social worker, or speech pathologist tried to assess Maria's capacity, Lee Ann refused to leave her mother's side and answered all the questions for her. When the ethics consultation was called and we went to Maria's room to set up a meeting, Lee Ann informed us that her mother probably wouldn't agree to it, although when we found Maria alone the next day, she agreed. Maria's family dynamics were complex. She didn't want to choose between her children. Lee Ann felt under appreciated and overwhelmed, and she believed the team did not like her. Darryl said he had a longstanding conflict with Lee Ann and didn't trust her to make his mother's health care decisions. But in assessing Maria's capacity, we kept coming back to the core issues: To what extent can Maria be involved in her medical decisions? What does she prefer? How much has she reasoned about her options? …