• Julie W Childers and Robert Arnold.
• Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, The University of Pittsburgh, Pittsburgh, Pennsylvania, USA. Electronic address: childersjw2@upmc.edu.
• J Pain Symptom Manage. 2021 Sep 1; 62 (3): 657-661.

AbstractAutonomy, which gives individuals the right to make informed decisions about their medical treatment, is a central principle in Western bioethics. However, we often encounter patients for whom a family member seems to dominate medical decision-making, to the extent that clinicians become concerned that the patient is subject to excessive pressure or even coercion. In this article, we describe one such case and how we assess a decision-making process that involves family influence. This entails acknowledging that many individuals weigh their family members' preferences and/or well-being heavily in making medical decisions, and family norms for decision-making differ. A family member who tells their loved one "You can't give up now" is typically not ursurping the patient's liberty to make a different decision. However, there are some family influences which may be autonomy-limiting, including credible threats, or in situations of abuse. Aside from these scenarios, our role is not to alter a couple's long-standing dynamics and decision-making processes. However, for the patient who wants to assert herself, we can set the stage in a family meeting and amplify her voice. We must also attend to the emotional level of family members' statements. "I won't let you give up" might be more a statement of grief rather than a true reflection of their values or intent. Supporting the family member's coping may help to bring together what initially seem to be divergent goals. Exploring these decision-making dynamics is key to providing good palliative care.Copyright © 2021 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

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