How should a treatment team respond to the aggressive requests of a patient’s substitute decision-making?

Healthcare providers often deal with substitute decision-makers (SDM) who make unreasonable or uninformed requests. Sometimes these are for tests or scans that aren’t indicated. In other cases, the request is for a treatment that might harm the patient, such as requests for ivermectin to treat Covid-19 infection. Providers handle these situations well, but, in some cases, the requests can strain the therapeutic relationship to the point where the provider is unsure whether the SDM is making decisions in the best interest of the patient.

Ethicists can be helpful in these situations. One value is that the ethicist can take some of the load off the provider. By taking the time to hear the SDM’s concerns, the ethicist can help the SDM feel listened to and work to find a solution. Most of the time, the SDM is acting in good faith to help the patient. Since providers are busy, they often can’t devote the time to working with SDMs of this type, which leads to tensions. Another benefit of the ethicist’s presence is that the ethicist can identify the source of the concern. Sometimes, an SDM will request a test because they have a concern that they haven’t articulated to the doctor. Even though the test isn’t indicated, their concern can be addressed in other ways.