Employees and Teams Who Succeed. A Neurologist’s View

What is the best way to ensure employees and teams succeed?  Some executives and managers praise, encourage, let people work at their own pace and time, let them work in their own ways, and from time to time make gentle suggestions for improvement.

Others  say this is “soft,” “touchy-feely”. They direct people firmly, or ride them, or tell them exactly what to do, or chastise or punish errors or falling behind, or compare people unfavorably with colleagues, or use favoritism as carrot-and-stick. Some use do these without realizing it.

Is the first approach soft? Do any of  the second ones work?

What we now know about the brain tells us about both approaches. The brain is hard-wired to turn off creativity and intuition if the brain senses danger of any kind. The brain decides what danger is; we don’t decide. Scientific studies show that a firm, chastising, criticizing management style signals danger. A hint of disapproval turns off most of the brain. Only a small sliver still thinks. That sliver can only function in a tight box of linear  thoughts    (a àbàc). It’s not very productive.

The same studies show the first method is highly effective. Praise, encouragement, freedom to work how one wishes, and gentle suggestions motivate success and do it well.  They turn on nerve cells and circuits in the brain that inspire individuals and teams to do their best.

Why? Dr. David Rock reviewed the science in The Neuroleadership Journal 1 (2008).  He summed up influences on traits he calls “SCARF”:

  • Status,
  • Certainty,
  • Autonomy,
  • Relatedness, and
  • Fairness.

Increasing these five traits increases productivity by increasing comfort,  creativity, and intuition. Going against any one of the traits, just one, shuts down effectiveness and productivity. They shut down in a fraction of a second; it takes hard work over a long time to get them back.

Status in Rock’s term means social status, intellectual status; or a personal sense of honor and worth within a group, a department, an organization, or a company.

Certainty means knowing from moment to moment how an action will influence efforts. The efforts may be to get a effect one wants or they may be to avoid errors. Certainty is a subconscious state of the brain when planning or carrying out complex tasks.

Autonomy means freely choosing between possibilities. Autonomy gives a person or a group the sense they are in control of what they are doing.

Relatedness means feeling part of a group of friends. Lack of relatedness is what someone feels when s/he has to face an enemy or believes they are outsiders instead of members of a clique.

Fairness means feeling that authorities treat you just as they treat others: no prejudices, no insiders, no favoritism.

All of us like these traits. Your reports like these traits and know when the traits are gone. You as a report or subordinate feel these traits and their absence. You as a manager probably don’t feel them, whether you use them or avoid them.

A manager who is abrupt or uses a carrot-and-stick may not intend to undercut the SCARF traits. S/he may not recognize s/he is undercutting anything. What counts is how the reports feel. How reports feel determines their effectiveness and productivity.

What is going on in the brain? Most of the brain deals with subconscious actions and with reflexes. A critical part of the brain is the nerve cells and connections that trigger reflexes to get us out of danger.  They make sure we avoid enemies or threats. This is survival. It is a basic need.

Fig 1. Drawing of brain from the left side

Fig 1. Drawing of brain from the left side

The need to survive is much stronger than its opposite gratification. Gratification is wanting to be with people we love and things we love, wanting to stay with a supportive group, enjoying what we are doing, getting rewards. The reflexes in the brain that support survival are much stronger than the reflexes that underlie gratification.

Fig. 2. Lobes of brain and their functions. Frontal lobe: controlling movements (motor and pre-motor strips); motor output of language,  higher intellectual or executive functions, including "pre-frontal cortex". Parietal lobe: sensations from skin, joints, tendons, much of body. Occipital lobe: various aspects of vision. Temporal lobe: hearing, balance, (nearby: taste), putting together and interpreting language; interpreting vision; memory, emotions, sense of smell.

Fig. 2. Lobes of brain and their functions. Frontal lobe: controlling movements (motor and pre-motor strips); motor output of language, higher intellectual or executive functions, including “pre-frontal cortex”. Parietal lobe: sensations from skin, joints, tendons, much of body. Occipital lobe: various aspects of vision. Temporal lobe: hearing, balance, (nearby: taste), putting together and interpreting language; interpreting vision; memory, emotions, sense of smell.

The parts of the brain that deal with survival are small, on the front surface of the brain and low down on the front sides. They are nerve cells in the ¼-inch-thin outer layer or cortex. The area is what deals with linear, logical  thinking. It’s called the “pre-frontal cortex”  (see Figure 3).

Fig. 3. Mesial (middle) surface of brain, cut from back to front, top to bottom, and looked at from the middle surface. The visible priotions of teh major lobes are marked, as is the cerebellum (balance, smoothness of movement, repetitive movements) the midbrain including the pons, and the hind-brain of medulla. Grey matter is tinted light blue. White matter (pathways of axons) is tinted orange. The pre-frontal cortex is tinted brown. The limbic system (see text) is tinted dark blue.

Fig. 3. Mesial (middle) surface of brain, cut from back to front, top to bottom, and looked at from the middle surface. The visible priotions of teh major lobes are marked, as is the cerebellum (balance, smoothness of movement, repetitive movements) the midbrain including the pons, and the hind-brain of medulla. Grey matter is tinted light blue. White matter (pathways of axons) is tinted orange. The pre-frontal cortex is tinted brown. The limbic system (see text) is tinted dark blue.

Reflexes act and work in a few thousands of a second. The subconscious brain treats anything that threatens a SCARF trait as  a danger or a threat. Danger threatens survival.  Our need to survive is much stronger than our wish to be gratified. Threats of all kinds signal a nucleus, a collection of nerve cells, deep in the brain on each side called the amygdala (see Figures 4, 5, and 6).

Fig. 4. Drawing to show the deep nuclei of the brain in relation to the outer surface of the hemisphere. Thalamus largely handles sensory input. Putamen and caudate handle preparation for movement and setting up proximal muscle movements(like the upper arms and trunk) to support the movement of the more distal muscles (like movers of the fingers) The amygdala is laregly concnerned with recognizing danger and foes.

Fig. 4. Drawing to show the deep nuclei of the brain in relation to the outer surface of the hemisphere. Thalamus largely handles sensory input. Putamen and caudate handle preparation for movement and setting up proximal muscle movements(like the upper arms and trunk) to support the movement of the more distal muscles (like movers of the fingers) The amygdala is laregly concnerned with recognizing danger and foes.

When the amygdala perceive a threat, they act instantly to put the rest of the brain into “fight-or-flight” mode. Emotions switch to fear and anger (temporal lobe, see Figures 1, 2, 3, and 6).  Bad memories come up, memories of fearful events and things that made us angry (hippocampus, Figure 6). Part of the brain signals disgust and nausea (the insula, see Figure 6). The intuitive functions of the brain shut down. The only thinking part of the brain that is active is the prefrontal cortex (see Figure 3). This thin layer works only with learned, linear, logical behaviors; nothing else. All of this together is the survival  mode.

Fig 5 (above) and Fig 6 (below). Relations of the amhgdala to the sense of smell (olfactory bulb and front of temporal lobe) and to emotions and memory (cingulate gyrus and hippocampus). The cingulate gyrus is on the mesail or middle surface of the hemisphere on either side, and continues backward and downwards as the hippocampus of the termporal lobe.l Fig. 5 shows the strucutres in relation to the hemispheres. Fig. 6 shows the structures with teh hemispheres removed.

Fig 5 (above) and Fig 6 (below). Relations of the amhgdala to the sense of smell (olfactory bulb and front of temporal lobe) and to emotions and memory (cingulate gyrus and hippocampus). The cingulate gyrus is on the mesail or middle surface of the hemisphere on either side, and continues backward and downwards as the hippocampus of the termporal lobe.l
Fig. 5 shows the strucutres in relation to the hemispheres. Fig. 6 shows the structures with teh hemispheres removed.

You can’t avoid the survival mode. When we are trying to survive we cannot deal with non-linear problems.  We cannot be creative. We cannot think out of the box.  We cannot be kind to others, we cannot work out new ways of doing things, and we cannot use intuition. Survival is every man for himself, every woman for herself. Teamwork and social abilities disappear.

The “slice” would be perpendicular to the groove between the hemispheres, towards the front half of the temporal lobe. Purple-blue is grey matter (cortex, various nuclei). Orange is white matter (axons connecting one area of the brain with another). The temporal lobes are the lower bulges on either side. The frontal lobes are the bulges above. The white inverted triangle in the middle is the two lateral ventricles (full of spinal fluid) covered by the (orange) connection between the two hemispheres (corpus callosum). The area of the cingulate gyrus and the area of the amygdala are labelled. So is the insula, the cortical region involved with the sense of taste and with disgust and nausea.

Managers and executives beware: the more often people perceive threats to survival  at their workplace, the worse the consequences. Behavior gets worse. Efficiency and productivity go down. It takes longer and longer to restore people’s brains to a neutral state, let alone an aligned, creative state. And yes, simply working the wrong way with reports  and teams about their work in your organization is interpreted by the brain as survival, not as simply being told to work a certain way!

Aren’t there exceptions — firefighters, soldiers, emergency room doctors and nurses — people trained to deal with emergencies and disasters? These highly-trained people are actually hyper-focused in the survival mode of their expertise. In this mode, they use linear logic instead of creativity. They are not exceptions. They’ve just been trained in many specific linear processes the rest of us don’t know.

I only know one protection from automatic fight-or-flight. It is to get trained in tools of consciousness that include skills to block negative emotional responses and to discreate the unpleasant emotions that are stirred up. How to do it is beyond the scope of this white paper. Contact me.

What we know about the brain gives a clear message to executives, managers, organizations and companies. Encourage the SCARF traits.

1) Treat employees, staff, colleagues, and teams so they feel valued.

2) Treat them so  they are certain that whatever they try will be appreciated whether it succeeds or fails.

3) Treat them so they know they can make their own decisions about what to do, how to do it, and when to do it.

4) Make them feel they are valuable members of an organization in which superiors, peers, and people who report to them are friends not rivals.

5) Make sure no-one supervising them plays favorites.

Successful executive coaching and successful organization development follow these rules.  For example, in his book,  “What Got You Here Won’t Get You There”, executive coach Marshall Goldsmith considers 20 types of flaws in interpersonal behavior that damage relations in a company.  Let me link these flaws to SCARF categories. I don’t want to minimize the deep and broad analysis Goldsmith gives. I merely want to show that there is common ground between Goldsmith’s approach and Rock’s.

  • Problems with statusseem to me to underlie Goldsmith’s flaws of
    • needing to win too much,
    • needing to add too much value,
    • needing to tell the world how smart we are,
    • needing to make excuses,
    • needing to cling to the past to deflect blame,
    • refusing to express regret,
    • and an excessive need to be “me”.
    • Undermining certainty is likely
      • when a sentence begins with “no,” “but,” or “however”;
      • when you “explain why that won’t work”,
      • when you withhold information,
      • and when you “speak when angry: using emotional volatility as a management tool.”
      • Being unwilling to let people have autonomyunderlies
        • making destructive comments,
        • sarcasm,
        • cutting remarks;
        • withholding information,
        • and claiming credit you don’t deserve.
        • Several flaws destroy the sense of relatedness:
          • passing judgments,
          • making destructive comments,
          • speaking when angry,
          • failing to give proper recognition,
          • claiming credit you don’t deserve,
          • making excuses,
          • clinging to the past to deflect blame,
          • refusing to express regret,
          • failing to express gratitude,
          • and passing the buck.
          • Fairness is damaged by
            • failing to give proper recognition,
            • withholding information,
            • claiming credit you don’t deserve,
            • playing favorites,
            • and punishing the messenger.

Patrick Lencioni’s “The Five Dysfunctions of a Team” is about management consulting, “organization development”.  Again, my intent is merely to show common ground. I’m not trying to simplify Lencioni’s work.

  •  Absence of Trust is the bottom of Lencioni’s pyramid of dysfunctions. Absence of trust includes a lack of a sense of relatedness.
    • The members of a team may be assigned together,
    • but they are suspicious
    • and even afraid of each other.
    • They do not feel they are a group of aligned friends.
    • Often, they may be juggling for a sense of status.

The absence of trust and its underlying issues – restoring status and relatedness — is the first problem that needs to be solved when using Lencioni’s paradigm.

  •  Fear of Conflictis the second layer of the pyramid. Fear of conflict is
    • a fear of an open, free-flowing discussion.
    • Why? Because people on the team don’t trust each other.
    • Fear of conflict is an issue of relatedness.
    • Fear of conflict also means that the members of the team don’t feel autonomous
    • and lack certainty about their part in a discussion.
    •  Lack of Commitment implies a lack of
      • certainty
      • and relatedness.
      • Lack of commitment also means the teams’ members fear lack of autonomy
      • and that their status is threatened.
      •  Avoidance of Accountabilitycan come from problems with
        • certainty,
        • autonomy
        • and relatedness.
        • Avoidance of accountability is made worse
        • if the team’s members sense lack of fairness.
        •  Inattention to Resultscomes from the sum of these problems. The sum can be stated in Lencioni’s paradigm or in David Rock’s. It is the same:
          • people on a dysfunctional team don’t pay attention
            • to the results they get
            • or to the results they should be getting.
            • They can’t do it.
            • The amygdala and the pre-frontal cortex are on.
            • Much of the rest of the brain is off.
            • They are in fight-or-flight mode.

The message  is clear.

  • Pay attention to SCARF traits and needs.
  • Are you reinforcing the traits with your colleagues, reports, and subordinates,
    • letting their work gratify them?
    • Are you mistakenly undermining the traits,
      • consciously
      • or unconsciously,
      • putting your colleagues and subordinates into flight-or-fright mode
      • whose long term consequences prevent effectiveness and productivity?

Finding Alignment under Conflict to Change a Law

What happens if someone who is dying no longer wants food or water and can’t communicate this? What if the food or water is causing pain, breakdown of tissues, and increased suffering?

In the mid 1990’s, medical ethics emphasized patient choice and autonomy for quality of life and care in the last months of life: a patient should have the quality and the care s/he wanted. New York State’s law dated back several decades, to a time before ICU care or the modern conception of end-of-life care. It forbade removal of artificial hydration and nutrition.

What if the patient didn’t want them or the treatments were harmful? If a patient couldn’t communicate, they stayed – no matter prior conversations with doctors or with the medical proxy set up by a newer NY State law. Some hospitals and nursing homes felt the law allowed them or required them to impose their religious and moral beliefs on all patients in their care.

The bioethics committee of the state medical society debated the issue for two or three meetings. The committee consisted of 30 physicians, from academia, private practice; researchers on medical ethics, lawyers, administrators, and religious leaders. A few members of conservative religious and political backgrounds argued adamantly that the law could not be changed. Most of the liberal group couldn’t see a reason not to change it.

A year later, the state legislature and the Governor decided to revisit the law. They needed a decision of this committee: yes or no? We re-opened the debate. Again the conservative members dug in their heels. Again, the liberal majority couldn’t understand not updating the law.

When I explored, we all saw that each of the liberal members had withheld food and water when they thought that was the correct thing to do, ethically and medically. Had there ever been individual circumstances when the conservative physicians had withheld tube feedings or intravenous fluid from a particular patient who was dying?

Yes, they had often taken subtle cues from individual patients and then ceased artificial support. For example, a elderly man might tug at his nasogastric tube angrily to try to pull it out, over and over. Clearly he didn’t want it anymore; it was removed. An elderly woman consistently pushed away the baby-bottle full of Ensure given to her to suckle. Again, the sign was unmistakable and feeding was stopped.

The group in the minority could not imagine such subtleties being enshrined in law. That was the real issue.

I got unanimous consent from the committee to state this entire position as our consensus to the government: “a minority did withhold food and water in individual cases but believed the reasons too subtle to be enshrined in law; the majority thought the law should be changed.”

This I testified about in detail before the legislature and the Governor’s staff, being compassionate and truthful to both sides. The law was changed to allow patients and their proxies to withhold unwanted or harmful care, no matter the ethics or religion of the institution they were in.

Finding the Alignment under a Conflict over Vision and Drivers

Need for Modern Driving Regulations

What kind of vision cards should be used to test people for a driver’s license? In the late 1990s New York State’s Department of Motor Vehicles (DMV) used cards like those in a doctor’s office. There was a large black letter at the top, and, descending row by row, smaller and smaller, less and less black letters ending in a line of really tiny letters.

These had practical and theoretical problems – not as used by a doctor or an optician, but as used to qualify drivers. A driving applicant would read the card with one eye, moving to successively smaller print, and then do the same with the other eye – but the applicant had already read the card and could give correct answers with the second eye for a line of print the second eye couldn’t see clearly. There were other problems: for example, the way light fell on a card in one corner of a DMV office instead of another part could affect whether an applicant would pass or fail.

Members of the Vision Committee were at loggerheads.  The committee had half of the newly-formed Medical Advisory Board to the NYS Department of Motor Vehicles. The Department’s Commissioner and senior staff needed the Board’s input to craft new regulations and to defend them to the State Legislature. This was the first question the Commissioner and his staff had posed to the Advisory Board.

The question was whether or not to move to an entirely new form of vision cards. Newly  published work in the medical-scientific literature showed that a different kind of card was more accurate for driving tests, less influenced by variations in lighting, and less susceptible to cheating.

The new cards had 5 or 6 lines of  5 or 6 letters, different letters in different orders,  all letters the same size. The lines were chosen arbitrarily from the entire set of combinations of 26 letters taken 5 at a time in whatever order. The print size was the minimum an applicant had to be able to read standing at the DMV counter and looking at the card to show vision was sufficient for driving.

The DMV agent would pick out a line at random – “please read line 5 with your left eye,” and then another, “now, line 2 with your right eye”. No one could learn all the lines while concentrating on one, and there were too many variations in cards for anyone to memorize them ahead of time.

The Advisory Board had a mixture of professions. There were one or two physicians, research workers and other healthcare providers in each of the specialties the Commissioner thought would be helpful; representatives from state agencies dealing with aging, social services, and public safety; and representatives from enterprises and institutions throughout the state concerned with driving or with illnesses that might influence driving, the American Automobile Association for example. We were all assigned to one of two committees, Vision, and Loss of Motor Control (seizures, epilepsy, diabetes, sleep disorders, muscle disease).

I’d heard about the bitter division in the Vision Committee and as chair of the other committee, outside the conflict, I offered to help.

The first observation was that the physician-healthcare provider-scientist group were unanimously for the change. They had found a series of good, published research pointing to the need for change and to an effective method. They had not found anything that disagreed with these papers. They went through the articles with me and showed me why they felt this way.

The other representatives were all adamantly opposed, the ones whose background was in law or policy, not medical research. I asked, “why don’t you like the proposed change?” They pointed to the discussion section in the two most important papers. The authors had written that theirs was only one study, and the results should not be accepted until other laboratories had replicated the work. They had studied only a limited number of people – enough to give statistical validity, but perhaps a larger study would give different results. They had studied people of only one or two racial and ethnic groups living near their research center: things might be different with other groups in other parts of the country: “more research was needed.”

“See,” the  opponents said, “the scientists themselves don’t believe their conclusions are warranted.”

I explained. If the authors of a scientific paper did not put in disclaimers, editors and readers would worry the authors had been biased in favor of the what they found even before they started the work. People would worry the authors might have ignored details and information contrary to their conclusions. Any piece of research is considered interesting but it is not definitive until other groups, somewhere else in the world, have duplicated the results. Almost all scientists want to continue to have funding for their work  – these last sentences were code for “please give us additional funds so we can do more and learn more.”

Once the non-medical members understood the conventions of scientific work and writing, they agreed that the new system made sense and had clear advantages over the old. The committee wrote a unanimous recommendation to the Commissioner. The new cards were in use throughout the state within a few weeks.

 

 

 

Motivated Failing Toastmasters Clubs to Succeed

Motivated failing Toastmasters club to succeed by inspiring members to align purpose, mission, and activities; and coached a club that had failed with an earlier coach to achieve Select Distinguished status, the second highest club award:

In Toastmasters clubs,  members teach each other to improve public speaking skills and to develop leadership skills. The Toastmasters International (TMI) vision describes reality: “Toastmasters International empowers people to achieve their full potential and realize their dreams. Through our member clubs, people throughout the world can improve their communication and leadership skills, and find the courage to change.” (TMI website, http://www.toastmasters.org/Members/MembersFunctionalCategories/AboutTI/MissionVisionandValues.aspx)

One club near me was sliding towards failure because the two people were doing all the work and were burning out.  Another club was failing by having too few members, and continued to fail despite nine months’ work by another coach and Division officers. I present these problems together because I used similar methods to change matters.

Clubs are ranked each year by TMI by objective criteria that measure how much the club provides for its members’ success: not rated, Distinguished, Select Distinguished, and Presidential Distinguished. To succeed, each club needs enough members to spread work from meeting to meeting over the 6 months of each term and to provide a variety of perspectives in speeches, evaluations, and leadership. New members need to join to bring in new ideas and to replace members who leave.

In 2008, I was Area Governor for a group of Toastmaster Clubs.  The task was to help each club, to build on its strengths, to succeed, and to flourish. The first club was failing because there were only two committed officers.  They took most of the 7 or 8 roles in each meetings and they were getting tired and discouraged. Yet there were 20 or more members and new members joined at almost every meeting.

After attending several meetings and establish rapport, I got the club’s permission  to take half an hour at a meeting to discuss the club. Everyone gave input on what was important to them about a Toastmaster club and why.  We explored why each of those answers was important. I was careful not to comments myself except to agree and ask for more input.

The process inspired members to take on roles, to run for office and work hard at the officers’ duties. It inspired the exhausted officers to continue and to delegate. The Division Governor and I trained the new officers of the club. I continued to attend club meetings, and when asked, made suggestions from which the club chose solutions. Key members of adjacent clubs agreed to participate in meetings to set examples and they agreed to hold joint meetings. By the end of the year, the club was succeeding and now, three years later, it is flourishing.

In late January, 2010, I was asked to coach a club that had failed, and that again failed despite nine months’ work by another coach and Division officers. Clubs should have 20 members; this one had only four. It needed at least 13 to continue. After establishing rapport, I asked them what was important and why,  aligned them to want to succeed, set examples at meetings of how fill roles; and when asked, made suggestions from which the club chose its solutions. By late June, 2010, the club had 15 members and was Select Distinguished, the second highest level of excellence.

 

Saved 4-fold ROI by Aligning a Team

Saved medical center hundreds of thousands of dollars annually by reducing patient re-admission rates from 20 per month to almost none, by creating a high-performance 10-member team and aligning them to use modern treatments:

Patients with epilepsy at a major hospital in the South were being readmitted almost every month. They were either having break-through seizures or complications from their medicine.

Break-through seizures come despite someone taking  a seemingly correct dose of an accepted medicine. Sometimes a second problem has come up: stress, another illness. Sometimes the medicine isn’t really the right one. Sometimes the medicine isn’t monitored and the patient is actually getting too little or too much. Sometimes a well-meaning healthcare provider, untrained in neurology, adds a second medicine arbitrarily because the patient had a breakthrough seizure, so the seizures come more often and are more severe.

The treatments at this hospital were within accepted national standards, but the details were outmoded. Several problems were occurring and reoccurring.

The hospital wasn’t using the newer medicines which had fewer side-effects and fewer break-through seizures. Doses weren’t being monitored: neither blood levels in the morning before the first dose of the day, nor patient’s or the family recording on a calendar each seizure, (with a note of other matters: a cold. flu, an argument). ER doctors and nurse-practitioners merely increased the dose of the medicine after a breakthrough seizure was on, or added a second one, without getting advice from a neurologist.

The medical center asked me to create a new neurology service with 18 inpatient beds and a weekly clinic. There were excellent nurses, therapists, social workers, neurologists, and residents to staff it. They needed to be formed into a team, aligned, and inspired to high performance. Of course each one had been taught in school or early in clinical training to care for epilepsy, had done it for years, thought they knew how, and were no more interested in change for change’s sake than anybody else.

There was what was done; there was how it was done.

What was done is given below. It’s technical.

How? People on the team were already troubled by the frequent readmissions of  their epilepsy patients. Even the people most adverse to change were willing to try a new approach for 3 months to see if it made a difference. Over those months fewer and fewer patients were readmitted, and as more and more showed up in clinic grateful for the improved control of their epilepsy, the entire team became advocates for the new methods and used them enthusiastically: we developed into an aligned, high-performance team. The team was willing to consider ways to improve care for other neurological diseases.

The patients had better treatment and better quality of life. The readmissions decreased to essentially none. Each readmission cost the hospital thousands of dollars, and the dozens of seizure patients had in total 20 readmissions each month. The new approach and aligned team saved the medical center several hundred-thousands of dollars annually, well over four times my annual salary, a clear Return On Investment.

What was done was discussing and writing down the current, the modern approaches and teaching them to everyone on the team (including the neurologists and residents who rotated in for a month or two). The approaches were 1) using brand-name anti-epilepsy drugs (whose blood levels are more constant from refill to refill than generics), 2) using new drugs for the specific forms of epilepsy they treated best; 3) measuring blood levels before the first dose of the day (“trough” levels) once a month and 4) getting a trough level the morning after any break-through seizure; 5) having the ER physicians call a neurologist about patients who came in with a break-through seizure instead of arbitrarily changing the regimen, 6) adjusting doses so the blood levels were in the therapeutic range, avoiding side effects, 7) using seizure calendars as guides, and 8) following the patients regularly in the clinic.

Resolving a Common Conflict in Medical Ethics – the Child from the Other Coast

Mother was dying slowly. She could no longer communicate. Her health care proxy (this was in New York) wanted to follow Mother’s wishes and keep her comfortable – palliative care – and to withhold artificial food or hydration when matters got to that stage. The relatives who lived nearby all agreed. At 11 pm, the son from California, who had not seen her for 20 years, arrived on the ward unannounced and proclaimed that “everything must be done” to keep her alive. By “everything” he meant artificial everything – tubes for food, tubes for hydration, artificial breathing on a machine, a cardiac monitor and any resuscitation that might be indicated: a full-court press in the ICU.

Only 10% of us die quickly. An accident, murder, a massive heart attack or a stroke carries us off suddenly or we die quietly in our sleep one night. The other 90% of us have a long, protracted downhill course over many months, and with diseases like Alzheimer’s, over a few years.

In the early stages of a potentially fatal disease, say, cancer, there are curative treatments. Cancer might need surgery, maybe followed by radiation or chemotherapy. If the cancer recurs, a different form of chemotherapy may be worth a try, but the likelihood of cure becomes less and the probability of unpleasant side effects greater. By a third round, the patient or the doctor may hope “cure” but the reality is that the new cocktail will at best prolong life a few weeks, maybe a few months. It is almost certain the patient will have side effects that are hard to tolerate. Many patients who had been through three rounds have told me the side effects were worse than the disease.

If the patient, the family, or the doctor are adamant that “everything should be done” matters progress sooner or later to an ICU. Life support means mechanical respirators, intravenous tubes, nasogastric tubes or direct stomach tubes, dialysis, heart monitors. The ICU has constant noise, constant bright lights, rare privacy. It is expensive setting. The attitude “everything must be done” is responsible for the adage that we Americans spend more on a medical care in the last few months of a person’s life than in all the rest of their life combined.

The alternative to “everything” is called palliative care. It provides more care, more effective care, and more preventive care than “everything.” Palliative care is often given in a Hospice, the hospital, in a special house, often at the patient’s own home.

There is lots of treatment. It is directed at relieving the many symptoms every terminal illness produces as one organ system or another begins to slow down and shut down. Other treatment helps patient and family cope with problems getting around or using hands and arms, and with social needs and problems, and with legal issues, and with psychological issues and needs, and with the spiritual issues that invariably arise at the end of life.

Does the patient feel abandoned by God? Are there life goals that need to be completed? Does forgiveness need to be requested or accepted?

An entire team of doctors, nurses, social workers, therapists, counselors, and spiritual experts work in unison to help patient and family. Other experts, like lawyers, may get involved from time to time.

This has led to a paradox. In many parts of the country, ¼ to 1/3 of the patients who are admitted early to hospice end up surviving with a good quality of life for two or three years longer than expected. It is due to the quality and breadth of care, which are greater than care provided outside Hospice. The Hospice team pays a lot of attention to preventing problems and to catch and reverse them quickly. Many people who work in Hospice think the relief from spiritual worries and social concerns plays an important role.

There are notable legal cases in which world-renowned Hospices were sued by the Federal Government for fraud because so many of their patients lived so long after admission. Luckily, this foolishness seems to have ceased.

What about the conflict between the son from California and the rest of Mother’s family? It’s a fairly common issue. (When Mother lives in California, the outsider is the “daughter from New York”.)

The key is the 20-year absence. There has been estrangement, deliberate or not, maybe in reaction to some disagreement or slight, maybe not. The son has a mixed emotions and needs. He feels guilty. He is longing for love from Mother, and to be able to talk with her either to give forgiveness or more often to seek forgiveness. He was not around and did not participate in the discussions the medical team had with Mother and the family, so he does not understand the futility of “everything” care, and that it actually makes matters worse, increases the patient’s suffering, shortens life, and costs family and society emotional  and spiritual anguish and at least as much money as all the other medical costs throughout Mother’s life: all for a futile gesture. Futile, but well meant.

In our hospitals, three of us from the ethics committee would meet the son in a conference room on the ward. My colleagues were a nurse or social worker and someone from the community, usually a businessman with a strong interest in business ethics and medical ethics. I was the physician. We were joined by a senior nurse from the ward, the ward’s social worker, and sometimes the nurse who had cared for Mother the most in recent days.

The explanation was given kindly, gently, with compassion; never arguing. Each of us took part spontaneously. The gist of it was, “we understand. This has happened before. It doesn’t upset us. Your wishes are an expression of your love for Mother and your wanting to do the most for her, her comfort, and her happiness. Perhaps you are hoping against hope that she will wake up, by some miracle, and you’ll be able to talk with her. You’d like to make up, apologize, forgive or be forgiven. Actually, even though she is in a coma, we know she can feel and hear. If you stroke her forehead, hold her hand, talk quietly to her, some part of her will know, will understand, will appreciate what you are doing.”

Only when the son grasped this would we go on to explain that the kind of “everything care” he sought would make things worse; and we would talk about this only if he needed more reassurance that everything reasonable and helpful was indeed being done.