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Multidisciplinary and multi-professional teams exemplify an essential component of today’s healthcare systems. Through multidisciplinary teams different elements of care are coordinated and delivered. Multi-professional teams are believed to be an important factor of increased effectiveness in healthcare, especially for elderly patients. Given the multitude of health problems experienced by elderly patients, multidisciplinary teams can ensure that all health, social and cultural needs of patients will be met. Unfortunately, conflicts of duties and values in multidisciplinary teams are not uncommon. In case of geriatric care, end-of-life decisions generate the biggest controversies. At times, even the mere presence of a multi-professional team can cause a serious conflict of values for those patients, who want to be followed and monitored by a single medical specialist. In these situations, the best thing that members of a multi-professional team can do is to make decisions in accordance with patients’ needs, values and beliefs, through communication, negotiation and mediation. This paper will define the problem and discuss how it can be resolved with the help of virtue ethics theory.
Multi-professional multidisciplinary teams in geriatric care
Multidisciplinary teams have already become an essential part of most healthcare routines. Multi-professional teams no longer surprise anyone but, on the contrary, represent an advanced level of healthcare development in medical facilities. “A dictionary definition of a multidisciplinary (healthcare) team is a team of professionals including representatives of different disciplines who coordinate the contributions of each profession, which are not considered to overlap, in order to improve care” (Daly, Speedy & Jackson, 2009, p.210). In other words, multidisciplinary teams are those which are made of professionals in different fields of expertise, with the goal of providing quality care. Needless to say, the success of multidisciplinary teams, including those in geriatric care, builds on the principles of collaboration, cooperation, communication and negotiation. Multi-professional teams encompass professional values and ideals that rely on collaborative working and complement the goal of improving customer experiences and outcomes (Daly, Speedy & Jackson 2009). Effective communication is considered to be one of the most essential characteristics of multidisciplinary teams (Daly, Speedy & Jackson 2009). However, for multi-professional work to be effective, healthcare facilities must pursue a set of values.
The main values which healthcare organizations should demonstrate in order to promote effective multidisciplinary work include patient focus, customer orientation, and the major attention paid to the technical, professional and organizational issues affecting teamwork (Daly, Speedy & Jackson 2009). Members of multi-professional teams must be empowered to act for the benefit of patients and have skills and capacity to think systematically and holistically (Daly, Speedy & Jackson 2009). To achieve these goals and avoid ethical controversies, healthcare facilities need to make a shift away from parochial towards multidisciplinary activity, especially in aged care where end-of-life decisions have to be taken. The latter actually represent one of the major cornerstones in delivering quality multidisciplinary care to elderly patients, and conflicts of values/ duties that can hinder the development of productive caring frameworks.
Multi-professional teams bring together individuals working in diverse functional and professional backgrounds, and the skills, knowledge and experiences they bring to multidisciplinary teams can be equally useful and damaging to conflict resolution. In other words, these differences can lay the groundwork for the development of relevant decision making models or become the major source of conflicts within the teams. Conflicts of values and duties in multi-professional geriatric teams are rather common, stemming from the tasks to be performed by team members and the differences with which these tasks are being treated (Daly, Speedy & Jackson 2009). Many conflicts arise from the quality of relationships among team members, leading to reduced job satisfaction and increased stresses (Daly, Speedy & Jackson 2009). Yet, even these conflicts are easier to resolve than those which involve conflicts of duties and values. The latter usually presuppose choosing among two or more equally valuable alternatives, which makes the task of reaching a commonly agreed solution virtually impossible.
Conflicts of duties and values in elderly care: Observing the problem
According to Thompson, Melia and Boyd (2000), an ethical dilemma is a choice between two alternatives that are equally unsatisfactory. Multi-professional performance is associated with numerous ethical dilemmas. Conflicts of duty and conflicts of values are, probably, the most controversial aspects of performance in multi-professional teams. The example below will help to clarify the ethical problems faced by multi-professional teams providing aged care and define possible pathways to resolve the emerging ethical dilemmas.
Mrs. A. is a 86-year-old bedbound woman who is admitted to the hospital because of an acute change in her mental status (Carrese 2006). She is active and lively but requires assistance in all life activities except eating (Carrese 2006). Her medical history includes atrial fibrillation, critical aortic stenosis, depression and hypertension, as well as hip fracture 18 month preceding the current admission to the hospital (Carrese 2006). The problem is further aggravated by the fact that the patient is widowed and does not have children (Carrese 2006). The 71-year-old patient is her main health agent and the person responsible for managing her health affairs and, without regular medical support and nursing care, the patient is at risk for developing major health complications. However, the patient refuses to leave her house and go to live in a nursing home. Upon admission to the hospital, her vital signs show that her heart rate is rather slow and her blood pressure is below normal (Carrese 2006). She is diagnosed with urosepsis but she refuses to stay in the hospital (Carrese 2006). The multi-professional team strongly recommends that the patient remains in the hospital for a short rehabilitation period, but she is not interested in rehabilitation and wants to go home. Her mental state gradually returns to the baseline norm, but the multi-professional team serving the patient is faced with a serious ethical dilemma: is it ethical and acceptable to let a dependent, debilitated but mentally sane person go back home toward an unsafe situation? This is the case that was described by Carrese (2006) and this is the case that exposes the main ethical dangers of working in multi-professional geriatric teams.
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The situation with Mrs. A., as well as with many other elderly patients, often placed members of multi-professional teams between two equally unsatisfying alternatives: meeting the needs and desires of patients and, therefore, withholding treatment or, on the contrary, provide treatment and rehabilitation against their will. Few clinical decisions are more problematic than whether or not to provide patients with treatment against their will (Richards & Lindesay 1993; Branigan 2009). The main reason why such ethical dilemmas are extremely problematic is because they bring into conflict the duties and values that are central to quality geriatric care, namely, the duty to relieve patients’ suffering, the duty to save patients’ lives, and the duty to meet patients’ desires, wishes and needs (Richards & Lindesay 1993). In the western world, living wills have become a popular instrument of solving various ethical dilemmas, but living wills can hardly be treated as a universal solution to the problems faced by members of multidisciplinary teams when they are dealing with mentally incompetent patients. In most cases, the way towards the resolution of ethical dilemmas in geriatric care depends upon the circumstances and conditions in which these dilemmas emerge and can never be solved by means of various algorithms or checklists (Fulford 1989; Jacoby & Oppenheimer 1991; Richards & Lindesay 1993).
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Members of multi-professional teams need to find the desirable balance between the duty to protect patients’ lives, promote their well-being and protect them from harm, and the duty to respect patients’ wishes (Carrese 2006). Patients who are allowed to leave the hospital and come back home before the rehabilitation period is over are automatically exposed to the risks of harm and various health dangers. Nevertheless, present day multi-professional teams must recognize the growing role of patient participation in the treatment process: despite the benefits brought by patient participation, it also serves one of the fundamental sources of ethical dilemmas in geriatric care. The basic principles of nursing and medical care claim that all patients have the right for self-expression and self-determination, but in many cases, excessive utilization of these rights may lead to bad care decisions (Carrese 2006).
The conflicts of duties are not the only source of controversies in multi-professional geriatric teams. Very often, whether or not to withdraw treatment and whether or not to provide treatment depends upon the cultural and spiritual values exercised by both members of a multi-professional team and patients (Azhar & Varma 1995; Halstead 1986). “Although physicians should never assume patients will respond in a particular way because of their ethnic background, issues of life support should be discussed in a culturally sensitive way” (Klessig, 1992). While patients and members of multi-professional teams may hold to different values and beliefs, team members may face similar situations within their teams (Petrova, Dale & Fulford 2006). In this situation, the conflict will grow from the two different sources simultaneously, making the whole situation even more complicated. Despite the fact that healthcare organizations and nursing homes strive for greater diversity of employees, only those organizations which can manage diversity through improved communication and collaboration can use it for their benefit. As long as cultural patterns are closely related to the patterns of decision making surrounding geriatric care and death decisions, these cultural aspects of communication and decision making should be closely considered (Post, Puchalski & Larson 2000).
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Finally, there are considerable risks that the presence of a team by itself will reduce the quality of geriatric care and generate a serious ethical dilemma. Grumbach and Bodenheimer (2004) write that the creation of a healthcare team can erode job satisfaction for physicians who are used to work as single sources of care for elderly patients. In the meantime, teams may come in ethical conflicts with those patients, who believe that teams break the continuity of care provided by a single clinician (Grumbach & Bodenheimer 2004). Simply put, many patients, especially older ones, may want to develop more personal contacts with their healthcare professionals and obtain personalized care. In these situations, healthcare organizations will have to take a difficult decision, which meets the needs and desires of an elderly patient with no harm caused to patient’s health.
Solving ethical dilemmas in multi-professional geriatric teams with the help of virtue ethics theory
There are three ethical theories that can be applied here: utilitarianism, deontology and virtue ethics. In contrast to utilitarianism and deontology, virtue ethics tells us what we should be, but not what we should implement. Thus in our case the personnel should be more attentive and compassionate towards patients and also towards each other. Apparently, there is no way for multi-professional teams to avoid conflicts of values and duties. Therefore, the main question is how to solve these problems effectively. All decisions regarding ethical dilemmas and ethical choices demand thoughtful evaluation, discussion and communication skills (Anderson, Dean & Piech 2006; Pat, Suen & Chair 2009; Rodning 1992). Bearing in mind the priority of patients’ self-determination and autonomy values, all decisions regarding care should be based on patients’ beliefs, preferences and values (Anderson, Dean & Piech 2006). This being said, members of multi-professional teams must take steps to learn the values and beliefs of every patient, discuss the goals and expectations of care on the early stages of the treatment process, and establish a collaborative decision making model (Anderson, Dean & Piech 2006). When it comes to elderly patients, members of a multi-professional team must assure family members and relatives that patient needs are being heard.
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The most important task of any multi-professional team is to focus on balanced communication, consistency of care provision, and negotiation at all stages of the treatment process. The process of communication in health care is hardly straightforward, and the information produced by team members and the information delivered to the patient may differ substantially (Bowman 2000). One of the critical problems in multi-professional teams’ performance is in that they exercise a superior position over a sick and weak patient, which increases the distance between their goals and patient’s priorities. In these situations, especially when end-of-life decisions have to be made, patients and their family members simply fail to absorb the information provided by team members (Bowman 2000). This is why communication and cooperation are the best ways to understand the values and beliefs on which the patient and medical professionals’ judgments rest. This understanding will pave the way for resolving the most controversial ethical dilemmas in multi-professional geriatric teams.
Ethical dilemmas greatly affect the quality and professionalism of geriatric care. The situation is particularly difficult with multi-professional teams, where several professionals in various fields of expertise are brought together to provide quality multidimensional geriatric care. Reasons why ethical dilemmas in multi-professional teams are so common are numerous. Basically, differences in patient and nurses and team members’ values result in conflicts of values and duties. Ethical dilemmas often emerge in end-of-life decisions, when the balance of patient needs and healthcare priorities has to be achieved. More often than not, members of multi-professional teams face the dilemma of meeting patient needs vs. doing no harm. Even the presence of a multi-professional team may become a serious ethical problem, when elderly patients want to be served by a single nurse for the purpose of medical care continuity. Objectively, eliminating the risks of ethical dilemmas in multi-professional teams is never possible, since diversity of values, duties and beliefs is one of the major prerequisites for creating a multidisciplinary team and achieving the desired health outcomes. Whenever faced with a conflict of duty or values, the best members of a multi-professional team can do is to make decisions in accordance with patients’ needs, values and beliefs, through communication, negotiation and mediation. All decisions regarding ethical dilemmas in medical and nursing care require thoughtful consideration. Communication and cooperation are the best ways to understand the values and beliefs on which the patient and medical professionals’ judgments rest. This understanding will pave the way for resolving the most controversial ethical dilemmas in multi-professional geriatric teams.