Table 1.
Clinical Conversation (what the parties are saying)Family Medicine Ethics Reflection (what the physician is thinking)
Dr. Smith: Ted, today is a good news day. You're doing well. I can tell you have been continuing to exercise: your weight is down another 5 pounds since your last visit. Your blood pressure looks great. And you are now eligible for Medicare.Normalize the conversation with patients. Talking about advance care planning is just part of the work I do in providing comprehensive, person-centered primary care.
Mr. Jones: That's right. I came in a few weeks ago and took care of the paperwork with the help of your care manager. Thanks to her!Have in mind a repertoire of possible ethical approaches. As I address issues, I try to integrate principles, case-based analysis, virtues, rules, narrative ethics, and the ethics of care throughout the conversation.
Dr. Smith: Thanks to you. Medicare doesn't pay much, but it does help us make our bottom line. Speaking of bottom lines, Ted, how are your worries going?
Mr. Jones: I still worry. I don't want to knock off one day, just like my dad and granddad.
Dr. Smith: I hear you.Have available a repertoire of ready responses. When discussing medical issues, some people want me to be honest and to the point; others want me to “sugar coat” things. Do you have a preference for how I discuss information with you? Let's build on our relationship together.
Mr. Jones: That's why I've been trying to lose the weight I put on after I got laid off.
Dr. Smith: Good to hear.
Mr. Jones: And take my pills.
Dr. Smith: Mmm-hmm.
Mr. Jones: And Betty still seems to like havin' me around. You know, we've been together 25 years now. I got something right the second time around. And all our kids, on both sides, have their own kids.Assess where patients are, emotionally and cognitively. Have you considered how medical decisions should be made, or who could or should make such decisions, were you not able to make them for yourself? Have you already discussed these issues with someone else? What experiences, thoughts, values, and emotions came up in the process?
Dr. Smith: Great. I think you're doing really well right now. I am not at all worried about you like you are—you're taking much better care of yourself than either your dad or his dad did—and I like to bring up advance care planning when people reach 65.
    Do you know what advance care planning is?Generalize care—make it inclusive and supportive. As you think about your future, is there anything else we can do to help you? While it may well be stressful for you and your family to plan ahead, it is one of the best and most enduring gifts you can give them. Let your family know that you love them and trust them.
Mr. Jones: I do now. Your care manager gave me some info on it when she signed me up for Medicare.
Dr. Smith: And?
Mr. Jones: I am up for talking about it, but I just don't think Betty could make decisions. Don't get me wrong, I don't want to go before my time, but should it happen, I don't want to be a vegetable, either. And I don't think Betty could pull the plug on that one.Recognize the challenge. Talking about these situations is very difficult, but it will help us make decisions for you—as much as possible anyway—in the same way that you would make them for yourself, if you could. I want to support Respect for Autonomy.
Dr. Smith: Have you thought about who could or should make decisions for you if you are not able to make them for yourself? Or is your family one in which everybody together makes important life decisions? What about your kids?Explore family relationships, style, and specifics. Who is in your family? How does your family make decisions together? Who among your family members might be the best spokesperson(s) to talk with me or other doctors or nurses, were you not able to talk for yourself?
While I support Autonomy, I need to balance it with my experience of past cases and detailed knowledge of this patient and this family. I need to fill in the 4 Boxes: Medical Indications, Patient Preferences, Quality of Life, Contextual Features.
Mr. Jones: Let me think on that, and let's talk more at my next visit.
Dr. Smith: Good by me. I am going to suggest you talk with Betty and your kids, right up front, between now and then. It can be a scary thing, but once it's done, everyone sleeps easier. Trust me on that. It helps families out. And invite them to come in with you when you return.Encourage conversations with family/loved ones. Are you comfortable discussing your medical and personal values with your family? Do you need suggestions on how to talk about these issues? The virtues of compassion, courage, and trust are part of all these conversations.
Mr. Jones: Thanks, doc. Bye now.
Dr. Smith: See you soon. And be sure to bring in those papers the care manager gave you. I look forward to hearing how it all goes.Use time wisely. We don't need to come up with the answers to all of these questions today. Sometimes, the best plan is simply planning follow-up. I know that the virtue of phronesis—practical wisdom—is ever present in the office.
At the next visit
Dr. Smith (shaking hands): Nice to see you, Ted, Mrs. Jones.Acknowledge uncertainty. None of us can clearly predict the future. I can review a few examples of common clinical situations for you, but the future is still ultimately unknown. And discernment needs time.
Mr. Jones: Doc, I brought Betty with me to go over what we talked about last time, and I brought those papers. There are a few things I don't understand.
Dr. Smith: There always are. It's complicated stuff. I suppose that's why I am here to help. What questions?Continue to think broadly about the common theoretical approaches to addressing ethical questions. Looking at your particular medical situation from several perspectives may help both of us make good decisions if and when things get complicated.
Mrs. Jones: I am going to butt in. Ted's always worried about his heart, but with all this running he's been doing, I am worried that he is going to get run over. What then?
Mr. Jones: Betty, just wait…
Dr. Smith: Just a moment, Ted. Betty has a good point. None of us can see into the future—I certainly can't. The three of us talking here and these forms are all to help us out, regardless of what the future brings, or when. It's about knowing what your thoughts and feelings are, so that if it ever happened that you weren't able to make decisions for yourself, about your own medical care, someone else, a loved one, could help me to help you out. Does that make sense?Address specific issues, from the patient's perspective. Are there specific treatments that you clearly know you do want—or that you clearly know you do not want—to be done to you, under any circumstances? Do you have a clear guiding “rule” for us? How do you see your story playing out?
Mr. Jones: It does. But what would happen if I get run over?Accept diversity of opinion. I know that some people, for example, really want to avoid pain. Others, often for religious reasons, want to live as long as possible. Some people want to live only if they can be awake, talking and thinking clearly. Still others want treatments only if those treatments will help them get out of the hospital and back home. Some people want not to be a burden to their family. What values, virtues, principles and details of your situation and your care are important to you?
Dr. Smith: Well, have you thought about if there are specific treatments that you are completely certain you do want to have done to you or that you are completely certain you do not want to have done to you?
Mr. Jones: Well, we talked about it and I'm sure I don't want anybody pumping on my chest. I watched my dad go through that, and it didn't help one bit. It's hard to know what to do and what's most important.
Dr. Smith: Any thoughts from your side of things, Mrs. Jones?Touch on life's meaning through narrative. Tell me, what are the most meaningful parts of your life now? How do you imagine that might change in the future? What are your next chapters?
Mrs. Jones: I am not so sure I agree, but—yes, we did talk about it—and he is really sure about this. Now, Ted doesn't think I can be the one to make decisions, but we've been together a long time—you know this is both our second marriages, but we made it work—and I'll be damned if we put this on someone else.Empower patients to empower their surrogate decision-makers. Are you comfortable giving your loved ones your blessing, telling them that it really is OK for them to use their judgment and simply do their best so that they can tell this next part of your story? To help your surrogates make caring decisions that are both thoughtful and practical, are you able to suggest that they make decisions for you in the same way that they would make them for themselves? At the end of the day, we all want to take the best care of you.
Mr. Jones: I'm okay with that. I really do trust you, Betty, to use that good common sense of yours. It's why I married you. (Winking). Well, partly…
Mrs. Jones: I trust you, too, Ted. Now don't go knockin' off on me tomorrow. (All chuckle.)
Dr. Smith: Ted and I, and all the doctors and nurses in your care, will all work together—we'll do our best—to make sure that doesn't happen.Support a team approach/broaden the “I” of personal care. When I am not available or on call, one of my professional colleagues will be there to help, either by phone or in person.
    And all of the medical team will be here to assist both of you and your family in making decisions, too. Now—and in the future—however you all think we can best help.I know that the concept of shared decision-making is key for all of us.
    Okay, Ted?
Mr. Jones: Okay.
Dr. Smith: So let's pull out that form and spend the time we have walking through what it says. I'll help guide you as best I can. Then you can take it home, if you want, and think about it some more, and I'll be happy to have our care manager follow up with you. I also want you to know that the one certainty in life is that things change, so anytime you want to review this information, or I think we need to, I am here.Focus on the person. Document as a reflection of the patient's concerns. Advance directive forms are important because they enable us to write down your thoughts for your family and to put them into the medical record. It takes what we have talked about today and interprets it for doctors and nurses and your loved ones. Let me know if you have any concerns as we go through it together.
Mr. Jones: Sounds good. Let's do it.