Topic	Introduced in chapter
Ethics committee	1
A caring response	2
Honesty and integrity	2
Patient rights and responsibilities	2
Moral distress	3
Deontology	4
Ethics of care	4
Narrative reasoning	4
Moral courage	4
Autonomy, beneficence, nonmaleficence, veracity	4
Six-step process	5
Responsibility	5
Team loyalty	9
Confidentiality	10
Trust	10

Introduction

Communication is an essential part of healthcare delivery. You have just read in the previous chapter about the importance of confidentiality. Confidence in another is a foundational aspect of the patient–health professional relationship. Confidentiality is about holding information. Communication is about sharing information. How information is shared in health care is vitally important. In this chapter, we turn to the ethical dimensions of sharing information in finding a caring response.

Consider the following scenario: Mary Beth is riding the train on her morning commute into work. She works as a recreational therapist in an inpatient mental health clinic. Sitting across from her is a young woman having a conversation on her cell phone. The young woman disregards her public surroundings, talking loudly throughout the call. Others on the train cannot help but overhear her as she talks openly in this shared space. Her conversation details a discussion she had last night with her mother about her sister’s new husband. She elaborates how they suspect that the new husband has a serious problem with alcohol. She talks with detail of his drinking patterns and behaviors. She shares her concern regarding potential depression and abuse. Many individuals try to distance themselves from this young woman, but the train is full. They look away, reading their papers and listening to music. Mary Beth has neither with her. She closes her eyes and secretly hopes the young woman’s cell phone will run out of battery life.

Reflection

Have you ever experienced such a situation? If so, what has been your reaction?

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Is anything happening in this conversation that seems unethical? Why or why not?

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This scenario highlights a social communication. It is a communication shared between two individuals through the long accepted mode of telephone technology. We believe the communication is not unethical but clearly demonstrates poor judgment and etiquette. The cell phone user may see the conversation as normal social discourse; however, it violates the privacy of both the people in the conversation and the commuters.

Reflection

What if the young woman talking on her cell phone was a health care provider sharing the story of a patient she treated? Would that be different? If so, how?

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Communication

Communication is identified by many as a key foundational aspect of therapeutic relationships.1 Multiple research studies have shown that effective communication is an essential tool for the development of a successful treatment plan, improved patient knowledge, adherence to treatment regimes, and improved psychosocial and behavioral outcomes. Communication happens on many levels and in many ways. We do it so often that we often neglect to think of it or actualize its importance. Levetown helps highlights this well when she states “communication is the most common ‘procedure’ in medicine.”² We communicate through spoken and written words and languages. We communicate nonverbally. Nonverbal communication is expressed through body language, gestures, and mannerisms. We also communicate through various technologic means. Some of these are well established, such as telephones and pagers. Some are newer technologies, such as cellular phones and e-mail. Some are evolving technologies, such as blogs, video conferencing, text messages, and social networking sites. Health professionals communicate directly with the patient him or herself and are also responsible for communicating effectively with other providers, family members, schools, interpreters, payers, and other stakeholders to achieve the best care delivery. To do so, skilled communication is necessary.

The goal of this chapter is not to provide a comprehensive overview of communication in health care settings but rather to highlight how ethical problems may present surrounding such communications. Miscommunications and poor communications often precipitate ethical problems. In the pages that follow, we hope that you will gain a broader understanding of the role of skilled communication in achieving a caring response.

The purpose of communication

A primary goal of health care communication is to achieve successful information transfer and exchange. It is a means of informing and advising our patients. But it is also about much more. It includes active listening. Active listening is used when a health professional listens to the patient’s verbal and nonverbal communication. Active listening includes attention to cues in the conversation. It includes responding and validating to convey understanding. Communication also includes educating, collaborating, coordinating, decision making, and partnering. Through communication, health care providers develop a relational dynamic with the patient, which when successful, serves to facilitate shared decision making. Shared decision making is the concept that decisions are made based on an underlying assumption of mutual respect and joint interest. Health professionals have both the opportunity and the duty to shape communications to hold respect in the relationship.

Shared decision making

Shared decision making values patient autonomy. Shared decision making is a process in which information is exchanged not from professional to patient but between professional and patient. Professionals sufficiently inform patients regarding the health options and best available evidence supporting those options, and patients share with providers their values, goals, and preferences.3 In this way, decisions are better informed. The professional and patient then work together to arrive at the best decision option. In this model, because information is shared, the two partners can negotiate and commit to a collaborative agreement regarding health care decisions.⁴

Summary

Shared decision making is a tool for a caring response.

The Story of Beth Tottle, Mrs. Uwilla, and Her Family

Mrs. Uwilla is a 67-year-old woman from Haiti. She came to the United States to visit and assist her daughter and family with the birth of their second child. She is a widow and the mother of six children, two deceased, three living in Haiti, and one in the United States. Mrs. Uwilla is non-English speaking; her native language is a dialect of French Creole. Of modest means, Mrs. Uwilla supported herself caring for her grandchildren and other children in her rural Haitian village. A short while after arriving in the United States, Mrs. Uwilla collapsed on the sidewalk while walking with her daughter. She was taken to Mercy Trauma Center where it was determined that she sustained a severe subarachnoid hemorrhage from a ruptured cerebral aneurysm. She was admitted to the hospital and underwent a life-saving, emergent hemicraniectomy, a procedure in which the neurosurgeon removes a portion of the skull bone to allow for brain swelling. While in the intensive care unit (ICU), she underwent placement of a tracheostomy and a gastrostomy tube (G-tube). She was successfully taken off of mechanical ventilation but was unable to eat and continued to be fed via G-tube. Mrs. Uwilla was nonverbal and immobile and maintained a very low level of consciousness. Her tracheostomy was closed, but she remained minimally interactive and dependent in all activities of daily living.

Beth Tottle, the case manager assigned to care for Mrs. Uwilla, kept up to date regarding her clinical condition. It was her job to help coordinate a safe discharge plan for all patients on the neurosurgery unit. Mrs. Uwilla’s daughter, Mica, delivered her new child and was able to visit her mother only sporadically as she was recovering from childbirth and had no other help at home. Beth was helping to coordinate Mrs. Uwilla’s care and asked Mica if anyone else could help. Mica told Beth that Mica’s older brother Rene might be able to come to the United States to help. Rene had called the unit several times and kept up to date via phone calls. He is a religious man and was concerned for his mother. The doctors had told him it would take a few months for them to replace Mrs. Uwilla’s skull bone and for the swelling to resolve. They have also told him that she may be able to receive rehabilitative care in the United States but that they would not know her options for sure until the case management team was able to do some searching.

After several phone conversations, Beth Tottle was able to convince Rene Uwilla to travel to the United States. He arrived 1 month into her hospitalization to assist the family in decision making regarding the next steps. He cried on seeing his mother in her hospital room. The day after he arrived, a family/team meeting was scheduled, during which Mrs. Uwilla’s slow but steady progress to date was outlined. The resident physician told Mr. Uwilla that they need to make some decisions regarding her future care, most significantly her “code status.” He states, “We are recommending your mom be made do not resuscitate (DNR). This means if her heart stops, we won’t restart it.” The case manager and other members of the rehabilitative team also begin to educate Mr. Uwilla regarding the discharge planning process. Because Mrs. Uwilla is not a U.S. citizen and lacks health insurance, her options for rehabilitation are limited. They ask Mr. Uwilla to consider taking his mother back home to Haiti, although they realize that the care there will be suboptimal.

Mr. Uwilla is overwhelmed and angry and immediately responds to this by saying, “Now I see why it was so urgent to come here. You told me she would be rehabilitated here but now say that option is ‘very limited.’ Not only do you want me to get my mother out of here, you also want me to kill her. You see her as work—she is a human being! This is the woman who taught me to love. I can’t be expected to immediately manage all of this. I am only one person.” The team was caught off guard by his response, many of them looking to each other for assistance.

Reflection

What do you think led to Mr. Uwilla’s response?

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What are the communication needs of this family?

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The six-step process in communication

Step 1: gather relevant information

Beth Tottle’s (and the care team’s) duties of beneficence and veracity dictate that she must attempt to assess Mr. Uwilla’s statement accurately. It is possible that Mr. Uwilla is asking the team this question because he wants them to reassure him that he does not have to face the uncertainty of his mother’s recovery alone. It also is possible that he wants reassurance that he is part of the decision making process for his mom’s care. Differences in power are quite prevalent in communication. These differences should be lessened in the shared decision making model; however, research shows that they continue to be prevalent in how professionals communicate with patients and families.5

It is important to be as sensitive as possible to the implicit, unspoken messages that are contained in language. This is true of all verbal communications between individuals. Here, Mr. Uwilla is expressing a nameless fear with the statement that the team wants him “to kill his mom.” We know that he is a religious man and that there may be religious or spiritual beliefs associated with what he hears. He may have heard that in the United States individuals of an older age are not valued and perceive that the staff would like her to die. He is in a vulnerable situation at the moment. Often times, when DNR status is raised, it can be perceived as abandonment of the patient or family.

The health professionals must also acknowledge the fact that Mr. Uwilla and his family are from a Haitian culture. This is a different culture from that of the Western, predominately white care providers. Currently no one on the care team is of this cultural background. Beth herself knows very little from the Haitian point of view. She cannot help but wonder what illness or disability even means in the Uwilla’s culture? This cultural point of view becomes ethically relevant information because it can serve to drive the decision making process.

Mr. Uwilla’s anxiety is likely heightened by the feelings of helplessness and insecurity that arise when a loved one has an uncertain prognosis. Patients and family members are not the only ones who do not like uncertainty; health professionals often have difficulty with it as well. Uncertainty is a concept that implies limitations to knowledge of a particular outcome.⁶ We often do not have adequate statistics to present a likely future course for patient conditions as seriously compromised as Mrs. Uwilla’s. In neurosurgery, outcome after hemicraniectomy has been traditionally measured according to survival and level of disability; however, researchers and clinicians are now looking at measures of quality of life as well. Mr. Uwilla’s real question may concern the extent of his mother’s anticipated recovery. How will he know how much and when she will get better? Everyone has told him her recovery will be a long road. What does that mean? He may be asking beyond “What if her heart stops beating,” to “Will you still care for her?” or “What is at the end of this tunnel?”

In summary, the first important step in Beth Tottle’s assessment of this situation is to gather the relevant information by gaining a better understanding of what Mr. Uwilla heard, what he is asking, and what the sources of his discomfort are.