If this simple dilemma had been approached as a shared decision to leverage opportunity within the dilemma—which usually requires a transparent conversation about physician bias and patient bias about care priorities—it’s entirely possible over time to guide and coach the patient toward reduced dependence on Vicodin and valium and increase lifestyle approaches and cholesterol medications to address life-threatening risks. Reduction in dependence and increased lifestyle approaches require a trusting and mutually beneficial relationship.
Failure to recognize and act on dilemmas, on the other hand, often leads to reduction of trust and mutually beneficial relationship. Navigating and leveraging dilemmas requires a shift in focus from “I will solve your problem” toward “we will navigate and leverage our dilemma together”. This vital shift likely requires that the physician move away from an individual hero mind-set toward a team-player mind-set; away from a fixed mind-set toward a growth-and-learning-mind-set; away from an either/or mind-set toward a both/and mind-set These mind-set shifts and reframings become even more vital when navigating and leveraging complex dilemmas and polarities.
Complex Dilemmas
These dilemmas are multiple, inter-dependent, relational, multi-factorial in nature. They require that multi-options be engaged—that actually or potentially impact each other. Addressing complex dilemmas can feel like providing a menu of options with various upsides and downsides. Yet, the options are not single destinations, they are pathways that are linked and inter-dependent. Unlike Complicated Problems, they do not naturally fall into a series of ordered decision-nodes. They may feel like 5 bouncing beach balls linked together with elastic dancing across the sea. Pulling on one beach ball can lead to an array of impacts on the other balls, including bouncing off the head of the patient and knocking him under the waves.
This complexity can emerge from the complexity of challenges faced by the patient—physical, mental, behavioral, social, financial, cultural—or can emerge through complexity of potential pathways to follow and the other people (Family, friends, employers, insurance companies) involved in the decisions to be made. Complexity is often magnified by emotional and relational contexts—fear, anger, guilt, grief and the like. Let’s look at a common complex dilemma faced by patients every day.
Marty is the sole breadwinner of a family of 6 children and 12 grandchildren—married to Martha for 35 years. He has struggled with multiple health conditions, including glaucoma, diabetes, heart disease, kidney failure requiring dialysis, chronic pain, and depression. Despite these conditions, he has managed to keep working and raise his family, send many of his children to college, etc. Three days ago, he learned he has metastatic lung cancer from his years of smoking and likely only has 6 months to live unless he signs up for experimental chemotherapy that could extend his life by months or end it more quickly due to risk of serious infections related to suppressing his immune system or further damaging his kidneys.
In addition, his daughter is a Naturopath. She has advised him of a mushroom in from Japan that has shown promise with lung cancer in small studies. Another child feels very strongly that he needs to quit his job and travel with their mother since he has been promising to do that for the last 10 years but work has not been flexible enough to allow it. Faced with impending death and many options, some favored by some children and his wife, others favored by his doctors.
