Nancy Neveloff Dubler, mediator in the final moments of life, dies at 82

Nancy Neveloff Dubler, a medical ethicist who pioneered the use of hospital bedside mediation to navigate the complex dynamics between stubborn doctors, anguished family members, and patients in their final days, died April 14 at her home on the Upper West Side of Manhattan. She was 82 years old.

The cause was heart and lung disease, his family said.

A Harvard-educated lawyer who won the presidency as an undergraduate by campaigning to disband student government, Ms. Dubler was a revolutionary figure in health care who sought, in her words, to “level the playing field” and “amplify non-medical voices” in complex medical situations, especially when deciding next steps for the sickest patients.

In 1978, Dubler founded the Bioethics Consultation Service at Montefiore Medical Center in the Bronx. Among the first such teams in the country, the service employed lawyers, bioethicists, and even philosophers who, like doctors on call, carried pagers that alerted them to emergency ethical issues.

Bioethics consultants have emerged as a medical subspecialty following revolutionary advances in technology, pharmaceuticals, and surgical techniques.

“Our technology now allows us to confer several decades of healthy, productive life through procedures such as cardiac catheterization or triple bypass surgery,” Dubler wrote in her book. “Yet it also allows us to take a body with a massive brain hemorrhage, hook it up to a machine, and keep it nominally “alive,” with functioning organs on a bed, with no hope of recovery.”

Such advances can lead to friction among doctors, who have been trained for generations to keep patients alive with whatever tools are available; family members, who may fight over their often incapacitated loved ones; and hospital administrators, who may fear legal action.

The questions Ms. Dubler and her team faced were complex and heartbreaking.

Should a premature baby who is unlikely to survive be intubated? Should an unconscious patient whose religious beliefs prohibit blood transfusions receive one because a family member requests it? Should a teenager be allowed to forgo excruciating treatment for terminal cancer?

“Nancy brought a human face to bioethics focused on empathy and inclusivity, really giving a voice to those who didn't have one,” Tia Powell, who succeeded Ms. Dubler at Montefiore, said in an interview.

Ms. Dubler's first tactic in entering into these discussions was to sit down with the families.

“They've been in the hospital for who knows how long,” he said during a presentation at Columbia University in 2018, “and no one has ever sat down and talked to them” — especially doctors. “They run in and they run out, and they all look pretty much the same in their white coats.”

Often, Ms. Dubler encountered family members who did not want their loved ones to know that they, the patients, were terminally ill.

In an essay for the Hastings Center, a bioethics research institute in Garrison, New York, Ms. Dubler recalled a case involving an elderly man who was seriously ill but breathing on his own after being removed from a ventilator.

The man was clearly dying, but his children did not want to involve him in discussions with hospital staff about further life-extending measures.

“I met with the children and explained that the team felt obligated to discuss with the patient what type of care he or she would like in the future,” Ms. Dubler wrote. “The children exploded, saying this was unacceptable.”

Ms. Dubler – dispassionate, but tenacious – continued the conversation.

“After much discussion about the patient and what a great person and a great dad he had been,” she wrote, “I asked him what it would be like if I opened a discussion with him with three questions: 'Do you want to discuss your future care with Me? Would you like me to talk to your children about future care? And do you want to have this discussion without your children present?'”

The children feared that such a conversation might make their father realize that he was dying. What he needed, they thought, was hope.

“I described studies that indicated that when family members try to protect the patient from bad news, the patient usually knows the worst, and silence often results in feelings of abandonment,” Dubler wrote.

This affected the children. She approached the man's bedside.

“The patient was clearly very weak and tired,” Ms. Dubler wrote. “I asked the patient if, since he had recently been extubated, he would agree to be intubated again if the doctors deemed it necessary. He said, “I would think about it.” The children said they will think about it too.”

The process worked.

“The full-blown conflict over whether to 'tell dad' has subsided,” he wrote. “The mediation in this case worked with the children to create an approach towards their father that they could tolerate, if not embrace.”

Nancy Ann Neveloff was born on November 28, 1941 in Bayport, New York, on the south shore of Long Island. Her parents, Aaron and Bess (Molinoff) Neveloff, owned a pharmacy under their home.

As a student at Barnard College, she studied religion with a focus on Sanskrit. While there, she ran for campus president as a single-issue candidate.

“He won by a landslide and really disbanded student government,” his classmate, Nancy Piore, said in an interview. (It was eventually reinstated.)

Ms. Piore recalled once seeing Ms. Dubler reading a James Bond novel in her academic guise. “She was a character,” she said, “and she was a real force.”

After graduating in 1964, he studied law at Harvard, where he met Walter Dubler, a recent Ph.D. graduate in English, at a New Year's Eve party. They married in 1967, the year she graduated, and moved to New York City, where she worked as an attorney for convicts, child delinquents and alcoholics.

“If Nancy and I were doing anything after work, we would meet her at the men's shelter,” Mr. Dubler said in an interview. “But after a meeting there, I told her I was too picky and would meet her somewhere else. But she was very interested in that kind of thing.

He joined Montefiore in 1975 to deal with legal and ethical issues and three years later established the Bioethics Consultation Service.

Outside of her work at the hospital, Ms. Dubler advocated for equal access to medical care for prisoners. She has also served on committees that develop ethical procedures for stem cell research and the allocation of ventilators in case of shortages.

In addition to her husband, she is survived by a daughter, Ariela Dubler; one son, Josh Dubler; and five grandchildren.

Ms. Dubler's colleagues suggested that her greatest legacy was the creation of a certification program at Montefiore to train doctors, nurses and hospital staff in bioethics.

One of the program's graduates, a doctor, was at Ms. Dubler's hospital bedside when, in her final months, she gathered her medical team and family around her to declare that she was going home and not coming back.

“He was clearly in awe of her,” Ms. Dubler's son-in-law, Jesse Furman, a federal judge in the Southern District of New York, said of the doctor. “He saw how, even in her reduced state, she was able to have control of her own treatment and her own death.”

The doctor told her he was honored to be there for her.

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