Family Mediation in End-of-Life Disputes: The Role of Bioethics Mediation Blog #5

STADA Process

Akah (2016) has described the STADA Process for bioethics mediation as outlined by Liebman

and Dubler in their book Bioethics Mediation: A Guide to Shaping Shared Solutions (2004).

STADA stands for Sit down, Tell me, Admire, Discuss, and Ask. If the patient is competent and

able to participate, the STADA steps can be modified to include the patient in the conversations.

During the initial step of the STADA process, Sit down, the mediator begins by asking

the family (or surrogate) to Tell them about their loved one, the patient. The goal is to

give the family a forum and to empower the family members.

The next step is to Admire and affirm what the family has shared about the patient. The mediator uses this opportunity to acknowledge and commend the family for their concern for the patient. Next, the Discuss step provides a forum for the healthcare team to talk about the diagnosis, prognosis, and treatment options and answer any questions.

Lastly, the family is Asked what the patient's wishes would be if they could speak for

themselves. At this time, the family and healthcare providers are to consider the patient's

preferences and values as understood by the family or surrogate and consider the

lifestyle that would result from the treatment choices presented by the healthcare team.

If no mediation agreement is reached, the mediator should tell the family what is likely to

happen next. It may be that the case will be brought before the hospital ethics committee for

review, or the case may be sent to the legal department to see if judicial intervention is needed.

Each of these possibilities and their implications must be explained to the family. (Akah, 2016).

Sources of Conflict in Bioethics Mediation

Much of the conflict experienced during end-of-life is due to the stressors associated with being

terminally ill or having a terminally ill loved one. According to Moorkamp (2017), one specific

source of conflict includes poor communication from the physician. Often the families may be

perceived as "disruptive, hard to manage, and at odds with staff" (Moorkamp, 2017). It is not

uncommon for families to feel their concerns and desires are ignored or not given merit.

Families believe they are considered a non-essential component of the decision-making

process by the medical staff. When families feel they are being heard, they are more attentive to

medical staff and more open to working with them to find the best treatment option for the

patient. The significance of good communication cannot be understated when healthcare

settings are often thought to engage in "secret, hidden, authoritarian, and private decision

making that emerges only as a progress note or a consultant script in the medical chart"

(Moorkamp, 2017).

Physicians might avoid end-of-life conversations with patients and families for several reasons

(Larson & Toobin, 2000). Many physicians fear or lack training in giving bad news and causing

pain to the patient and family. Physicians often view death as the enemy to be defeated. They

also anticipate disagreements with the patient or family and fear medical-legal battles. Lastly,

physicians may not understand the laws related to advance directives (Larson & Tobin, 2000).

Avoidance of discussing the patient's prognosis can lead to the family's needs not being met

(Akah, 2016).

Another source of conflict in end-of-life decisions is patient autonomy which gives patients' a

right to control their treatment according to their wishes. In a recent study, Benson (2020) found

that tensions often arose between patients and caregivers when patients attempted to maintain

or regain autonomy. The patient's actions toward maintaining his or her autonomy appeared to

pose a direct threat to the physician's professional standards. In addition, struggles over which

family member has control are common in most conflicts. Caregivers have trouble giving

patients the authority to make decisions about their care, especially when it puts the patients at

risk or creates more work for the caregiver. Notably, some conflict over autonomy was about the

patients' unwillingness to assume authority in making their own care decisions or advocate for

what they needed. Although several caregivers indicate they struggled with patients' control,

some also found their autonomy as the primary caregiver challenged by extended family.

Caregivers viewed micromanagement by family members as a threat and a direct display of

mistrust. Family member suspicions were often about the caregiver fully disclosing patient

symptoms (Benson, 2020). Conflicts of this nature can lead to patients receiving end-of-life care

inconsistent with their end-of-life care preferences (Karnik & Kanekar, 2016).

Thank you for your interest in this ongoing series. In the next blog I’ll be considering how cultural differences affect end-of life decisions.

Michele M. Davda has a B.S in Psychology and an M.S. in Neuroscience. She taught Biomedical Science at the STEM secondary level for a decade. She is a member and committee member of the Montana Mediation Association (MTMA).

This blog is meant to promote and increase awareness of Mediation, as well as to discuss the role that Mediation plays in conflict resolution. This blog series does not provide legal, medical, or psychological advice, and it should not be taken as a substitute for professional advice or treatment.

Citations

Akah, H. (2016). Expanding the scope of bioethics mediation: New opportunities to protect the autonomy of terminally ill patients. Knowledge Base. Retrieved October 5, 2021, from https://core.ac.uk/display/161946911.

Karnik, S., & Kanekar, A. (2016, May 5). Ethical issues surrounding end-of-life care: A narrative review. Healthcare (Basel, Switzerland). Retrieved September 17, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4934577/.

Larson, D. G. & Tobin, D. R. (2000, September 27). End-of-life conversations: Evolving practice and theory. JAMA. Retrieved November 3, 2021, from https://jamanetwork.com/journals/jama/fullarticle/193119.

Moorkamp, A. (2017). Don’t pull the plug on bioethics mediation: The use of mediation in health care settings and end of life situations. Journal of Dispute Resolution. Retrieved November 4, 2021, from https://scholarship.law.missouri.edu/cgi/viewcontent.cgi?article=1779&context=jdr.