Inquiry Before Advocacy

Inquiry before advocacy is an adage used in business¹ and also in palliative care. It reminds us to ask questions before suggesting solutions, to look before you leap.

Can you think of a time in your practice where you jumped to the solution before clearly understanding the problem? What happened?

“What are we doing here?” The intensive care unit (ICU) nurse nodded toward Mary Jane’s room. I was in the ICU to check on Mary Jane and assess and manage her symptoms.

“What do you mean?” I asked.

“I was just wondering what the plan is for her.” Again, she indicated Mary Jane.

“We are going to have another family meeting today.”

This time she shook her head like she was saying no and said, “Good. Someone needs to figure it out.”

As working nurses our practice is built on knowledge and experience. We draw on our professional experiences to help us understand our patients and to grasp the family dynamics of those we care for.

So it can be easy to think we have a full appreciation of a situation when we do not. We have cared for other patients with the same diagnosis, at the same age, with a similar response to treatment. We see how families behave, predictably and sometimes in unexpected ways.

We “know” what denial looks like. We “know” what is reasonable. We “know” what we would do if it were our family member. Years of experience can lead us to think we have seen it all.

We want to be advocates for our patients. And sometimes in our eagerness to do what is best for a patient we make assumptions. The experience that is a foundation to our practice can sometimes get in the way.

That is exactly what happened recently with two patients. In both situations well-meaning staff (nurses, doctors, and social workers) thought they knew what was best, but their experience blinded them.

Knowing the nuts and bolts of what is happening medically doesn’t necessarily translate to fully understanding a situation. Full understanding requires inquiry, and inquiry takes time. Because time is often in short supply we can fall back to “knowing” what is best.

The first patient, Mary Jane, was 52 and otherwise healthy. She had stage 4 cancer but was stable and getting treatment for her cancer when she developed pneumonia.

Although she required intubation Mary Jane’s pneumonia was considered treatable and potentially reversible. But after several days in the ICU a lack of inquiry reared its head. Because of her advanced cancer the questions started – “Is this what she wants or is it what the family wants?” and “Should we be treating her when she is terminal, wouldn’t it be kinder to let her go?” and “Why is the family extending her suffering.”

All three of the questions were asked based on concern for her. When Mary Jane was asked if she wanted to keep the tube in place she lifted her hand up toward the ceiling. Many felt that was her way of signaling her desire to go up to heaven.

It isn’t that I think the nurses and others were wrong to pose the questions, but embedded in them was a bias and that bias was based on an assumption that turned out to be incorrect.

The implicit belief was that with an incurable stage IV cancer we were promoting futile care. The questions were not geared toward open inquiry, they were geared toward assumptions.