Page 157 - JSOM Winter 2018

the SOCM to engage his emotional intelligence to attune to Stress of End-of-Life Decision-Making
the dying process. Jeff McMahan shed light on the fact that withholding or with-
drawing care can be ethically justified, but the experience of
When considering the SOCM’s new functions, the competen- engaging such medical decision-making is not without tension
cies needed to achieve each role will also expand beyond those for clinicians. In articulating the ethics, McMahan suggested
formed by training for life-saving interventions. Paul Kalanithi that if life-saving medical interventions will be effective and
suggested his entry into end-of-life care as a neurosurgical in- are self-sustaining and/or not taxing on the SOCM, then
tern “required moral, emotional, mental, and physical excel- the SOCM should provide life-sustaining care. However,
lence.” 9(p72) When he encountered death, Kalanithi found he if life-saving medical interventions will not sustain life and/
was wading “into the densest thick of emotional, scientific, or places undue burdens on the SOCM or mission, then the
and spiritual problems” and being asked to carve his own way SOCM should withhold care. In cases where life-saving
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out. 9(p72) Explicitly acknowledging death gives shape to the interventions no longer sustain life, then the SOCM or “his
SOCM’s expanded set of roles. Thinking about the SOCM’s partners or successors in the role he fills” can ethically with-
new roles within the structure of PFC also highlights that the draw care. 14(p264) Having provided a meticulous ethical analysis
SOCM will need to transition between roles. I now turn to justifying withholding or withdrawing care under certain cir-
the challenges associated with role transitions to establish that cumstances, McMahan closed by pointing out that clinicians
expanding the SOCM’s roles will create a new set of burdens experience this as morally murky terrain. 14
that need to be mitigated.
Justifying the SOCM’s actions as ethical is necessary so that
Stress of Role Transitions actions taken to withhold or withdraw care can be rationally
Blair Wheaton, a researcher who focuses on the impact of understood as not killing a comrade in arms. However, no
major life transitions and mental health, suggested that role amount of ethical argumentation can fully mitigate the stress
transitions are “inherently stressful due to the relocation and of end-of-life decision-making. The moral weight of living
transformation of identity.” 10(p211) Her point is that when sep- with the consequences of withholding or withdrawing care has
arated from contextual stress, major life transitions, including been made clear by research on moral distress. Ulrich et al.,
death, produce their own stress. Ashforth et al., experts on the medical ethicists interested in the emotional impact of moral
topic of minor role transition, explained that the difficulty of decision-making in clinicians, suggested that moral distress is
transitioning from one role to the next in the daily life comes felt when a clinician grapples with the rightness or wrongness
from “disengaging psychologically from the identity implied of a decision, treatment, or procedure “while feeling powerless
by one role and re-engaging in the dissimilar identity of a sec- to change the situation” or outcome. 15(p20) Their research indi-
ond role.” 11(p475) They noted that the more distinct the roles, cates that moral distress is heightened in clinicians who care
the more difficult the transition between roles. Highly distinct for patients in the intensive care unit and are faced with the
role transitions entail multiple boundary crossings at once, in- complex challenge of navigating the choppy waters of with-
cluding temporal, physical, spiritual, psychological, and social holding or withdrawing care. 15–18
boundaries. Moods, thoughts, and stress generated in one role
often spill over into another role when a person engages in Moral distress shows that decisions about withholding or
high-volume, high-magnitude micro role transitions. 11 withdrawing care are not made in a moral or medical vacuum.
Kalanithi bravely admitted his own lack of preparation when
Jeffrey Greenhaus and Nicholas Beutell, researchers who first faced with medical decisions about which operations
evaluate the impact role transition on work performance, de- would prolong life and under what conditions he felt unpre-
scribed how various conflicting pressures across micro roles pared: “How could I ever learn to make, and live with such
cause strain and stress on a person, affecting their performance judgement calls? . . . [W]ould knowledge alone be enough,
capability. They called this “inter-role conflict” and suggested with life and death hanging in the balance?” 9(p66) Deciding on
that “inter-role conflict is experienced when pressures arising the appropriate action related to withholding or withdrawing
in one role are incompatible with pressures arising in another treatment is a stress that will be exacerbated for the SOCM
role.” 12(p77) This inter-role conflict in relationship to death care who is also attending to other details related to moving,
is well articulated by Frank Ostaseski, founder of the Zen fighting, and providing medical care in austere conditions. If
Hospice Project, who has spent his entire adult life tending to unprepared for the intellectual and emotional complexity en-
the dying process and transitioning between various conflict- tailed in making determinations about withholding or with-
ing management, family, and pastoral roles. “Roles are neither drawing care, the SOCM’s stress will likely be exacerbated in
good nor bad. They are primarily functional and provide for the immediate situation as well as upon coming home from
some needed predictability in our lives . . . Each role comes deployment as the SOCM seeks to process the consequences
complete with its own expected set of behaviors, functions, of his or her decisions.
and responsibilities (batteries not included). It gets compli-
cated when one role conflicts with another.” 13(p119)
Conclusion: Implications for Future Research
By acknowledging the SOCM’s role in attending death, it I have covered a lot of ground thus far in exploring why it
becomes clear that the SOCM will be asked to perform the is important for SOF medicine to explicitly acknowledge the
stressful task of transitioning between roles. I turn next to es- SOCM’s role in attending death. It is not an exhaustive ex-
tablish the stress associated with end-of-life decision- making. ploration. Much remains uncharted. Because of the scope of
I show that although withholding or withdrawing care is eth- this article and my lack of subject matter expertise related to
ically justifiable, determining who does or does not receive the operational reality of combat casualty care, I have not ad-
life- sustaining care places a heavy burden on the SOCM’s dressed what competencies might be necessary for achieving
conscience. each role. To move the discussion forward toward practical

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