Negotiation and Dispute Resolution: A Podcast with Lee Lindquist and Alaine Murawski

12/29/22 • 50 min

GeriPal - A Geriatrics and Palliative Care Podcast

From discussing “taking away the keys to the car” for a cognitively impaired older adult to decisions to limit life sustaining treatments at the end of life, conflict and disagreement permeate everything that we do in medicine. How well though are we taught to handle conflict and disagreement? I’d say not well as I don’t think I’ve ever received a formal talk on the issue.

On today’s podcast we take a deep dive into the topic of Negotiation and Dispute Resolution training with Lee Lindquist and Alaine Murawski. We’ve had Lee on before to talk about her Plan your Lifespan project. We invited her back along with Alaine to talk about their work around negotiation training, including their work on NegotiAge, an online, AI based training intervention designed to teach negotiation skills to caregivers.

For an ever deeper dive into the subject of negotiation and dispute resolution, check out the following links (and for any caregivers interested in participating in the randomized clinical trial of the NegotiAge training, feel free email the NegotiAge Research Team at [email protected]):

Previous Episode

Is it time for geriatricians to get on board with lecanemab? Jason Karlawish and Ken Covinsky

We’ve talked at length on prior podcasts about the failures of aducnumab, Biogen, and the FDA’s decision to approve it.

But wait, there’s a shiny new anti-amyloid drug, lecanemab! (No it’s not just the French version of Aducanumab).

In an article in the NEJM (a published article this time, wonder of wonders!) lecanemab was shown to slow the rate of cognitive decline by 0.45 points on an 18 point cognitive scale compared to placebo. Wow! Wow? Wait, what?

On today’s podcast we talk with Jason Karlawish, who we’ve had on previously talking about his book The Problem of Alzheimer’s and with Aaron Kesselhim, to discuss FDA approval of Aducanumab, as well as frequent guest and host Ken Covinsky.

They debate today’s central question: is it time for geriatricians to get on board with lecanemab? Along the way we address:

Is this degree of slowed cognitive decline meaningful to patients or care partners?
What about the burdens, risks, and harms? Every 2 week visits for infusions, regular monitoring for brain swelling and bleeding, case report level risk of death?
Did the study do enough to address issues of inclusion and diversity by age, race and ethnicity, and multimorbidity?
What does this study say about the amyloid hypothesis?
Should the FDA approve, and under what conditions?

Their answers may surprise you.

As a preview of final thoughts at the end of the episode, Ken and Jason agree that the FDA should approve lecanemab conditional on a post-approval monitoring system and public access to study data, geriatricians should be prepared to have thoughtful conversations with patients about the risks and benefits of lecanemab in view of their values and priorities, and ultimately, that geriatricians should be open to prescribing it.

Wow!

The times, they are a changin.

-@AlexSmithMD

Next Episode

Conscientious Provision of MAID and Abortion: Robert Brody, Lori Freedman, Mara Buchbinder

Today’s podcast may be a stretch for our listeners. Please stick with us. No matter what your position on medical aid in dying (I’m ambivalent) or abortion (I’m pro-choice), this is a bioethics podcast, and I hope that we can all agree that the ethical issues at stake deserve a critical re-think. All three of today’s guests are well established bioethicists.

Let me start by quote/paraphrasing one of today’s guests, Mara Buchbinder, who puts her finger on the issue we talk about today:

“Typically when we think about conscience in medical ethics we think about it in terms of a negative claim of conscience, where a clinician refuses (or objects) to provide care. But what we know from my research and those of others, people also articulate a positive claim of conscience: they feel compelled to provide a service - whether it’s abortion provision or medical aid in dying - because of a deeply held conviction that this is the right thing to do.”

I’ll continue by quoting Lisa Harris, who wrote in the NEJM:

Bioethicists have focused on defining conditions under which conscientious refusals are acceptable but, with rare exceptions, have neglected to make the moral case for protecting the conscientious provision of care. Indeed, there is a real asymmetry between negative duties (to not do something) and positive duties (to do something) and, accordingly, between negative and positive claims of conscience. Violations of negative claims are considered morally worse than violations of positive ones.However, as bioethicist Mark Wicclair argues, the moral-asymmetry thesis does not provide adequate ethical justification for current conscience law, which protects only conscience-based refusals. Moral integrity can be injured as much by not performing an action required by one's core beliefs as by performing an action that contradicts those beliefs.

Lisa was writing about providing abortion care, but she just as easily could have been writing about providing medical aid in dying in states where it is illegal.

Today we wrestle with this issue of conscientious provision. We start by talking with Robert Brody, an internist who recalls physicians helping patients die during the height of the AIDS epidemic in San Francisco. Robert was first asked by one of his own patients for assistance in dying in 1991, far before aid in dying was legalized in California in 2016. Robert went on to be the founding chair of the board of Compassion and Choices, the major national advocacy organization for medical aid in dying. Today, medical aid in dying is legal in some 10 states, and illegal in others.

Also today, in the wake of the Supreme Court’s recent Dobbs decision, some 13 states ban abortion. To examine how clinicians might act in the face of such bans, we turn to Lori Freedman, who wrote a book about clinicians (primarily Ob-Gyn’s) who work in Catholic Hospitals. She describes the “workarounds” these clinicians used to skirt the rules in order to provide reproductive care for women.

We talk about the parallels between these issues at the beginning and end of life, and areas in which these parallels fall apart. For example, Jack Kevorkian excepted, clinicians have not been prosecuted for providing aid in dying in states where it is illegal. In contrast, there is a justified fear of prosecution of providing abortion care in states where it is illegal.

It took contemplation on a bike ride to put my finger on why I “wrestle” with the notion of conscientious provision. On the one hand, when I hear of Ob-Gyn’s in Catholic Healthcare systems using “workarounds” to provide reproductive care, I’m standing up and cheering on the inside. On the other hand, when I hear of workarounds to assist patients to die, or even euthanize them, I worry that we’ve gone back to a time when the doctor or nurse knows best - and should be morally permitted to do whatever they think is right, according to their conscience. Do we really trust all doctors and nurses so far? Would you, with your parents, trust any doctor or nurse to make such life or death decision...