Conflict resolution: Keep patients’ needs in mind
Expert offers suggestions for dealing with issues
Some conflicts among families of terminally ill patients or patients in vegetative states cannot be resolved, says an expert in doctor-patient communications, but much can be done before the conflict rises to the level of that in the family of Terri Schiavo.
Schiavo, the Florida woman whose parents and husband engaged in a long, bitter fight over whether her wish would be to end the artificial feeding that kept her alive for 15 years, died on March 31 after removal of her feeding tube.
"Clearly, [Schiavo’s family] had a breakdown in communication," says Robert M. Arnold, MD, director of the Institute for Doctor-Patient Communication section of the Palliative Care and Medical Ethics department of University of Pittsburgh. "But it was not just a breakdown; some conflicts are irresolvable, and this was clearly one of those conflicts."
There are steps to avoid or at least ease conflict when it arises between family members, between patients and their families, or between health care providers and patients or families, he says.
"One thing to remember is that it’s not about withdrawing care. It’s often about setting appropriate goals for that patient, and then making sure that the care provided is consistent with those goals," Arnold says.
Those goals need to be the goals the patient would want or at least agree with, Arnold says.
If disagreements appear to be forming, families should sit down for a discussion, but understand what the discussion is about.
"They should be really clear that this is not a discussion of what they want, because what they want is for their loved one to not be sick," he says. "It’s a question of, if that loved one were sitting there, what would he or she say?"
Encourage dialogue
In many cases, conflict leads to more talking, which leads to a resolution, Arnold says.
"We don’t like conflict, and we all try to avoid it whenever we can, and that’s understandable," he says. "But it may be better, and make us clearer about the problem if we discuss it and don’t pretend it doesn’t exist."
Unlike some in the medical and legal community, Arnold doesn’t see written advance directives, or living wills, as a reliable solution to conflict at the end of life.
"When making your advance directive, you can’t possibly anticipate every scenario," he says. "Written directives are, I’d say, somewhat important, in terms of giving you an initial view, or something around which to translate.
"But you still have to translate what the person meant. You have to interpret. And that’s the hard thing and where a lot of people can’t agree."
When disagreements that escalate to real conflicts can affect patient care, the best tool a physician can use is time — giving the family members time to talk about the disagreement.
"It depends on what the conflict is about, but time and space is about all we can do, and to not take sides," he says. "Most [physicians] are not trained as family therapists, and we shouldn’t try to be one."
Encouraging family members to try to understand each other’s opinions, even if they don’t agree, can be a helpful early step, says Arnold.
"Our initial inclination, when we’re in a conflict, is to try to convince the other person we’re right, rather than understand why it is that the other person doesn’t agree with you."
Making sure all parties who should be informed and involved in the discussion are included is important. Legal experts say malpractice suits arise when patients or family members feel they were ignored by physicians or left out of the decision-making process.
Some conflicts go unresolved
Alice Herb, JD, a medical ethicist and professor of family practice at State University of New York Health Science Center at Brooklyn, tells of a patient whose family had to, without warning, decide whether to sign a "do-not-resuscitate" order for their suddenly ill mother.
"This woman was working up until the minute she was taken to the hospital, and it was found she had a tumor in her lungs," Herb explains. "She was not old. She had four daughters, and she had appeared well up until that point.
"Resuscitating her would have caused her tremendous injury, due to the tumor, so the physician told the daughters they needed to sign a do-not-resuscitate order."
The daughters "couldn’t wrap their minds around the futility of resuscitation," Herb recalls. Even after hours of talking with the physician and with Herb, they could not agree.
Cases as contentious as Schiavo’s, she says, are few, but almost inevitably go to court. She says, in their desire to keep their daughter alive, Schiavo’s parents chose to put aside the fact that their daughter’s husband was her legally recognized surrogate.
"A doctor would have tremendous amount of problem [mediating] in that case," says Herb, who frequently works with patients and families to resolve conflict about health care. "I can be very persuasive, but there’s only so much I can do.
"You try to resolve it best you can, but if it gets to the point that it’s really frustrating, and you’ve called in a full ethics consults, and you just don’t know what to do next, then you find it going to court," she says. "But going to court is a mistake. I always encourage that we try to solve this without going to court."
Arnold, who has published research in resolving conflict, says there are steps that are advisable when disputes erupt over patient care.
First, recognize that a conflict exists. Next, the physician should prepare himself or herself for negotiation by identifying what is happening and empathize with the family and their emotions. Then, the physician is prepared to begin negotiating with the family in a nonjudgmental manner.
Focusing on the problem, rather than the person, sometimes proves helpful, he says. If the physician’s role does not help, or if it makes the conflict deepen, an impartial person or ethics consult should be called on.
"Dealing with conflict is a critical skill for physicians," Arnold says.
So is knowing when to call for help.
"When you’re in a conflict, it can be hard to see how to resolve it," he says. "I think, if it’s your own emotions that are there, it’s hard to see the other person’s story clearly, and you are out of control and can’t see a way out of the conflict, it’s a good idea to bring someone in to walk you through or mediate."
Physicians and nurses should keep in mind that issues surrounding end of life and decisions that must be made on behalf of a dying loved one lead to very powerful, emotional situations.
Palliative care experts say decisions to limit or withhold care to some extent are made thousands of times a day in the United States.
"A lot of times we do it so much that we forget how emotional it is for the families involved," Arnold notes.
- Robert M. Arnold, MD, Director of Institute for Doctor-Patient Communication, Palliative Care and Medical Ethics Section, University of Pittsburgh Medical Center. Phone: (412) 692-4834. E-mail: [email protected].
- Alice Herb, JD, Professor of Family Practice, Associate at Law, State University of New York Health Science Center at Brooklyn; Faculty Member, Health Advocacy, Sarah Lawrence College, Bronxville, NY. Phone: (212) 243-6662.
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