Public Release: 

Dealing with conflict in caring for the dying patient

How patients' families and physicians can build bridges

University of Pittsburgh Medical Center

PITTSBURGH, March 15 - How can a dying patient's family members and physicians get along when faced with difficult decisions on end-of-life treatment? The medical and emotional issues surrounding the care of a dying patient are both stressful and complicated, as highlighted in this week's Journal of the American Medical Association Clinician's Corner - Perspectives on Care at the Close of Life, which highlights the case of an 84-year-old woman with advanced dementia whose advance directive states that she does not want artificial nutrition or hydration. Over the course of her illness, her family and physicians conflict about the use of a short-term feeding tube and intravenous hydration.

From this case study, authors Robert M. Arnold M.D., Leo H. Criep chair in patient care, professor of medicine, and chief, section of palliative care and medical ethics at the University of Pittsburgh School of Medicine along with Anthony L. Back, M.D., an oncologist and medical ethicist from the University of Washington, Seattle sought ways to identify conflict and make recommendations on how to avoid the pitfalls and recognize disputes by employing useful communication tools.

"Physicians often assume that conflict is a bad thing and something that should be avoided, yet conflict handled well can be productive and the clarity that results can lead to clearer decision making and greater satisfaction," says Dr. Arnold. The five major types of conflict the authors identified include physician-family conflict, physician-nurse conflict, physician-physician conflict, family-family conflict and physician-patient conflict.

In the physician-family conflict scenario, family members may have concerns that hospitals do not respect their roles as caregivers, that they do not get the information they need or that the decisions are inconsistent with their wishes.

In the physician-nurse conflict scenario, previous studies in the intensive care unit suggest that physicians do not always acknowledge nurses' points of view. In one large survey, nurses rated physician value and respect for nurse collaboration significantly lower than did physicians. When asked what the most important element of a good working relationship is between physicians and nurses, physicians answered with "a willingness to help," while nurses answered with "mutual respect and trust."

Other conflicts include the physician-physician conflict scenario, the family-family conflict scenario and the physician-patient conflict setting.

The authors suggest one way to avoid these types of conflicts is to negotiate a course of treatment in which all parties have a say in how best to proceed with patient care so that potential conflicts may be solved in advance of the situation. The authors also discuss how showing empathy is important because many family members of critically ill patients often have a lot of anxiety, sadness and frustration over their loved one's situation.

Finally, using a step-wise approach, the authors recommend the following course of action if a dispute should erupt over patient care. The first step is to recognize that a conflict exists. A person cannot fix something unless they see the context of the problem. The next step for physicians is to prepare themselves for negotiation by identifying what happened and empathize with the family and their emotions. Once the physician is ready to negotiate with the family, the physician must begin the conversation in a non-judgmental manner. The authors suggest addressing and focusing on the problem instead of the person. Physicians need to listen carefully to the family members' concerns, respond empathetically and look for options that meet the needs of both parties. If the conflict still exists, it may be necessary to involve an impartial person who can act as a mediator.

"Dealing with conflict is a critical skill for physicians," says Dr. Arnold. "Recognizing and dealing with conflict can improve relationships, shed light on complicated clinical situations and the rewards include a grateful family and a sense of both personal and professional satisfaction."


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