Chaplain's Corner

The room was filled with in excess of 230 people, the organizers needed to change the venue for they had only expected 40.  Participants had gathered from the United States, Hong Kong and all over Canada to participate in a day long examination of a statement published in January 2008 by the College of Physicians and Surgeons of Manitoba titled, “Withholding and Withdrawing Life-Sustaining Treatment.”  The presenters included the Registrar of the College, a researcher from Halifax who had two Bachelors degrees, three Masters degrees and one Doctoral degree, several health care ethicists, physicians, members of the disabled community and many others.  All the presenters were well spoken, passionate and qualified to hold the opinions they expressed.

There were two aspects of the statement that captured the attention of and that became the focus of the day’s discussion.  The first had to do with a portion of the Statement that seeks to define the “minimum goal of life–sustaining treatment” and the other had to do with the conditions under which a physician could unilaterally make the decision to withhold or withdraw life-sustaining treatments. 

One of the event’s principle sponsors was the Vulnerable Persons and End of Life New Emerging Team Research Project, a coalition of people and organizations united to address some of the issues faced by vulnerable persons in our society (people with disabilities, cognitive and physical, people with chronic and degenerative diseases, people that are easily marginalized by a society that naturally favors the well, strong, independent people of society).

This team felt compelled to gather to address the College’s statement, “Withholding and Withdrawing Life-Sustaining Treatment” because they saw, within the statement, the possibility of the statement providing grounds for further marginalization and patronization of vulnerable people.  The Organizer announced at the beginning of the day that their hope was that this event would be a “safe place” for everyone to share their perspectives on the Statement and as I reflect on the event, it certainly seemed to achieve that goal.  There was significant opposition to the statement in the two regards mentioned above, as well as significant praise for the courage and energy the college exhibited in being proactive in the development of the statement. 

The strength of the statement is the weight it places on communication with the patient and family on the part of the physician.  It insistences that every possible means, including conflict resolution, be attempted prior to a doctor making a unilateral decision.  I’m no ethicist and neither do I have any credentials to comment on matters of the law; however, I feel a need to comment on this gathering and the above simply sets the contexts for the following thoughts.

As I listened, I was saddened to observe the growing distrust that exists in our society for medical professionals.  Now don’t believe for a moment that I am an advocate of blind trust in our health care system and the doctors whose services form the core around which the system revolves.  Health care administrators and physicians are people: fallible, flesh and blood people who despite their education and expertise struggle with the same prejudices and biases that the rest of us do.  Part of their training may be intended to enable and encourage them to identify these within themselves especially when they come to play on those they treat, but this is not always the case or can or should we expect it to be.

That is why communication is so very, very important and that is the strength of this document.  The document is fifteen pages long and communication with patients and families around beginning life-sustaining treatments, their effectiveness, when they are no longer effective and when they should be withdrawn is central to the statement.  But doctors are not always good communicators and neither are we.

We must remember that communication requires that a conversation move back and forth in two directions.  Therefore, not only are we to expect our physicians to develop good communication skills, but we must accept responsibility to do this as well.  But there are some significant obstacles to such communication happening, especially in situations where life-sustaining treatments are being considered or withdrawn.

One such obstacle is the difficulty we have in communicating and receiving “bad news”.   When the doctor can report that I am as “healthy as a horse” I don’t need much more.  My response may be “Thanks Doc, see you in five years.”  In fact that generally is my response.  But what if my doctor needed to tell me that he has found cancer, or heart disease, or diabetes or high blood pressure?   It must not be easy to deliver that kind of news and if you are like me, when I get “bad news” I sometimes just can’t think of some of the things I need and want to know about that news.  Sometimes when I hear “bad news” my brain freezes, I just get stuck on the “bad news” and am dumb-struck by it, my shock short circuits communication.

Another obstacle is time.  I hate to say it but we all know that doctors don’t have a lot of time to sit and chat; it is one of the realities of our health care system.  We may even feel guilty asking our doctor to take the time to help us understand what is going on in our bodies.  So, we tend to rush in and rush out and then once we are in the car we think, “Man, I should have asked the doctor…”

Another obstacle that is often not considered is the power differential that exists between ourselves and our doctors.  Knowledge gives power.  Experts, and doctors are medical experts, have specialized knowledge that we depend on and that gives them power over us.  Such knowledge differentials automatically created this power differential that can leave the party with the lesser knowledge fearful and apprehensive of upsetting the party with power.  This fear may result in our consenting to treatment we don’t understand and prevent us from asking our questions.  In the ethics of these power differentials, the party with the most power is always considered the party responsible to make efforts to level the differential by being sensitive to dynamics that may hinder real communication, but this doesn’t always happen.

Because trust is built on communication: good, open, honest communication over time results in the development of trust.  Discussions about the withholding or withdrawal of life-sustaining treatments should never occur when there is no trust in the relationship.  Sadly, at times the doctor we may have built trust with is often left out of these conversations, for too often they occur in a larger city hospital with specialists that we have no opportunity to build trust.  I don’t know that this can be remedied but the problem it creates needs to be acknowledged.

One of the strengths of this statement is that it sets the standard and expects that doctors who must deliver this kind of bad news will take the time, recognize the power differential and work hard to insure that you understand completely what is happening before life sustaining treatments are withheld or withdrawn.  You can expect this and request it without fear, for the College now expects it of their members.  Download a full copy of the statement here.