How does Marty choose between the many options before him? Can he take the mushroom his daughter advises with the Chemo or will that preclude him from the study? Does he focus on enjoying what limited time he has left or focus the full force of American healthcare and his own family’s energy on stretching out his life a bit longer, even if it risks being shorter due to complications of aggressive treatment? Or does he ignore all options and shift his focus to work where he is about to complete a very important legacy project that could improve the lives of thousands of people for years to come?

How does Marty navigate and leverage this complex array of choices and pathways, while optimizing his own life and enhancing his relationships along the way? Is he facing a series of either/ors or can he find a pathway through both/and or better/same/worse that provides him with the right way forward for him? Is quantity of life, quality of life for Marty most important? Or is he focused on how this will impact his family when he is gone? How much will all this cost? Will his insurance cover experimental treatments? Are there other Chemotherapies he is not hearing about because this particular cancer doctor favors this experimental approach? If the cancer doctor scoffs at the Mushroom will that reduce the likelihood of him taking it or increase the likelihood out of loyalty to his daughter who he loves dearly and trusts completely.

Complex dilemmas, when properly identified as such, often lead to more questions before decisions are made. These clarifying questions can help the decision-makers explore potential impacts of various pathways and seek out further information. Recognizing we are in the midst of a complex dilemma with inter-dependent, multiple pathways to choose from can be paralyzing for all parties involved and lead to relational challenges, heightened emotional states, and discomfort for all participants. A physician often needs more people to help her guide the decisions—expanding the team to include social workers, therapists, nurses, pharmacists to help delve more deeply into the complexity of the questions that emerge to help the patient navigate and leverage the complex dilemma.

Defining various options is essential, without the physician or team being overly invested in any particular option. Transparency of pro’s and con’s becomes essential to help the patient and family see the potential consequences of each pathway. “Can I try the Mushrooms for 3 months and then take the experimental chemo if the mushrooms aren’t helping” types of questions begin to emerge. This might be considered an attempt to create a serial pathway through various pathways—essentially reframing the complexity toward a complicated problem with serial steps. Yet, it can provide a pathway to maintain trusting relationships while allowing flexibility in approach.

It would not be unusual for the physician to respond “we can consider that, but if your cancer becomes too advance over the course of those three months or some new complication arises, that may exclude you from the experimental chemotherapy study” at which time the 100 page Experimental Chemo consent form is provided to the patient. So, that effort to shift from complex dilemma to complicated, serial problems is disrupted by the potential inter-dependance of the Mushroom and Experimental Chemo pathways, which may lead to the next attempt by the patient to find a relationally centered navigation of the complex dilemma.