Your Dysfunctional Child May Be The One to Keep You Alive

A few years ago, I spoke to a senior center audience about advanced directives and was greeted with a laugh and knowing nods when I commented that it is the child with whom the parent has the most dysfunctional relationship who will insist that the dying suffering parent be kept alive. Choose your surrogate carefully, I said, and be certain that it is someone who both knows your wishes and will follow them.

Times have changed. The social situations in which surrogates and patient families confront hospitals, nursing staffs and physicians have become more complex. As our country becomes increasingly multi ethnic and multicultural, hospitals are confronted with new family relationships and cultural demands. In some cultures, experiencing pain and suffering is part of dying process, and those representing the dying patient may give greater value to these cultural or family norms, than to the suffering of the dying patient. Discussions focusing on avoiding resuscitation or mechanical life support may fail because family members will not accept the responsibility for making a decision which they or others might conclude caused or hastened a loved-one's death. Demands to perform additional or repetitive tests or to keep a patient alive to allow family members to assemble from far-off corners of the world may be made. In some cases, calls to physicians in another country are made, and the surrogates and families demand the services or treatments these physicians have suggested, whether or not these services or treatments are consistent with American standards of medical practice.

In this complex multicultural consumer health care environment, physicians become confused about their own responsibilities as they lose track of the primary but potentially short-lived relationship with the dying patient and listen to/focus on the entreaties, demands and threats of surrogates and families.

My take on this is: (1) the standard of practice is "generally accepted professional standards of practice in the community/United States"; and (2) professional responsibility focuses on what is best for the patient (and consistent with the patient's wishes), not on different cultural practices or family demands if these are inconsistent with community/American accepted standards.