Friday, April 25, 2014

A Moral Community in the ICU

When I entered the room, my patient was surrounded by worried family.  They had lots of questions.  My concern was that I didn't know either the patient or family.  Dan had been brought to the ICU after a cardiac arrest outside the hospital.  The medics had gotten the heart restarted with CPR and shocks, but Dan was unconscious and on a ventilator.  So how to begin?

I introduced myself and explained that I needed to examine Dan and get more information from the family, then we would see what else we needed to do.  The anxiety was palpable.  He was soon to also be seen by the neurologist.  The cardiologist felt that his heart was "stable" and that he had had an arrhythmia, not a heart attack.

A son from Minneapolis was calling in.  The two other children at the bedside and Sam's wife, Marilynne, were in tears.

So how do I proceed from here?  The medical evaluations were pretty straight forward.  But communicating with the family is something I only learned over time.

Family conferences and  decision making with the medical providers occurs daily in the ICU, but the effectiveness varies widely.  A medical social worker and I developed a shared decision making pathway for medical providers to use.  One of the steps in the process is the concept of forming a moral community.

We would invite the family to meet in a quiet place, have a telephone/speaker for those unable to be there, and go around the room introducing ourselves.  The moral community concept is much like what goes on in an ethics committee discussion. The discussion centers around the patient's wishes and values respecting the patient's autonomy.  The community of caregivers (medical and family) begins to form around those values and wishes.  Caring, empathy and sharing are all key to begin to have the group act functionally as a moral community.  Modeling of these behaviors at times helps deal with the anger and frustration often present.

For more information please see our publication about a guide to shared decision making in serious illness.

Dan's family was devastated that he suffered irreversible brain death following his cardiac arrest.  Using shared decision making they agreed with removal of life support.  Allowing transparency, showing caring, focusing on Dan's wishes and values - all of these gave the family a sense that they were doing the right thing.


  1. I find though likely well-intended, the tone of this blog is more of the prevailing "doctor/social worker" as "Decider in Chief" contrary to the right of every human being to die when they wish to.

    The Canadian Supreme Court wisely handed down a decision several weeks ago, which essentially says that society does not have the right to force any one to go on living.

    "Shared decision making?" About MY life and my death.

    No, I say.

    Doctor just as I have no right or business in determining how and when you die, you have no inherent right or business determining how and when I die.

    And my choice would always be to be given, without delay the means or self-administered or administered aid-in-dying

    That right should be available to well as a setting (non hospice) in which all of us who so wish, can be helped to die without committees, relays, social workers, doctors et. al.

    Just a peaceful, calm setting with loved ones and friends, or comforting, loving staff if one is alone in the world.

    So Doctor, as nice and pleasant as you seem...we want you out of our deaths.

    1. Thanks for your comments. I happen to agree completely that your autonomy should prevail in end of life decisions. You might want to look at my post which discusses paternalism vs autonomy. Just FYI, the talk I give frequently is entitled "Your Life, Your Choices" which urges folks to make their wishes know ahead of time and to appoint a surrogate.

  2. Invaluable publication! Thank you so much for taking the time and effort to create it.