TAMPA — When conflicts over end-of-life care arise, try to understand the conflict and keep the lines of communication open, said three experts in palliative medicine at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.
“There's no question that conflicts will occur. The question is how to approach them,” said Dr. Kimberly S. Johnson, an attending physician at the Duke University Center for Palliative Care in Durham, N.C.
“The challenge for us is to be able to recognize the conflict and the nature of the conflict,” said Jennifer Gentry, an adult and geriatric nurse practitioner at the center.
Conflicts can arise when there are different views of the expected roles of family members and of the medical team, noted Dr. Toni Cutson, an attending physician at the center.
Physicians should remember that the family could have a history of problems before the medical team enters the picture. “We're not marriage or family counselors,” Dr. Cutson said. “We're certainly not asked to fix these relationships.” In addition, the team doesn't always know all of the facts. Even the “villain” has his own side to the story. In the case of an unsupportive husband, he might be trying to protect his children from their mother's illness and decline.
“When you see conflict, you're going to see emotion,” Ms. Gentry said. In handling emotions that arise in situations of conflict, she recommends remembering the mnemonic acronym NURSE: name the emotion; understand and relate to that emotion; respect everyone's feelings; support the patient; and explore the emotion by asking the patient and family to tell you more.
“Clear communication and transparency are important tools to resolve conflict,” Dr. Johnson said. Take the time to find out what the patient's and family's goals are, and avoid making assumptions, particularly about a patient/family's culture and relationships, Ms. Gentry advised.
When faced with a patient and family members experiencing conflict, Ms. Gentry recommended that physicians do the following:
▸ Try to understand that each family member might be at a different stage in terms of acceptance of a terminal illness.
▸ Realize that prior family conflict could be contributing to the current conflict over care.
▸ Try to define areas of agreement and disagreement to clarify the problem.
▸ Try time-limited trials of therapies to allow the family more time to make decisions.
▸ Have follow-up meetings to discuss concerns about care.
▸ When appropriate, suggest the family consult a psychiatric professional, ethics consultant, or spiritual adviser.