#225 The Family Meeting: Causes of Conflict

FAST FACTS AND CONCEPTS #225

THE FAMILY MEETING: causes of Conflict

David E Weissman MD, Timothy E Quill MD, and Robert M Arnold MD

Background When family meetings are conducted with the goal of helping a patient/family cope with a shift in goals from life-sustaining treatments to a more comfort focused approach, communication can break down. This Fast Fact reviews the common causes of conflict.

Recognizing Conflict When the patient/surrogates are not psychologically ready to accept the limits of medical interventions or the finality of the impending death, you will hear comments such as these: There must be some mistake; I know there are other treatments available; We want a second opinion; We believe in miracles; She is fighter, she will never give up; There must be something (medically) you can do. Health professionals may interpret these statements as ‘denial.’ But the term denial, by itself, is insufficient to help the clinician understand what is causing the impasse. Understanding the cause is essential in planning an effective strategy to move beyond the conflict to meet the needs of the patient and surrogates.

Information Gaps

• Inaccurate understanding of the patient’s medical condition (e.g. overly optimistic or pessimistic prognosis).
• Inconsistent information (One doctor tells us one thing and another something else.).
• Confusing information (e.g. use of medical jargon, multiple treatment options presented without a clear recommendation).
• Excessive information (well-meaning family/friends/clinicians providing information without full awareness of the problems).
• Genuine uncertainty (e.g., predicting functional outcome from a brain injury in its immediate aftermath may be impossible).
• Language/translation/cultural issues (We never tell someone they are dying in our culture.).

Treatment Goal Confusion

• Inconsistent treatments and unclear goals, often due to physician/patient/surrogate emotional issues (see below):
• Clinician initiated: We will keep your husband on blood pressure raising medicine but stop antibiotics.
• Family initiated: We want you to do CPR, but not intubate her.
• Differing priorities about disease-directed treatment and comfort-oriented treatment between clinicians and patient/family.
• Lack of clarity about goals when several things are going on simultaneously (advanced cancer, severe infection, respiratory failure – Isn’t the pneumonia potentially treatable?)

Emotions

• Grief (I don't know how I will live without him.)
• Fear/anxiety (I don't want to be responsible for ending my father's life. My family will be angry at me for doing this.)
• Guilt (I haven't visited my sister in 20 years. I should have been here for her.)
• Anger (My mother was very abusive, I've never forgiven her; you are just giving up on her.)
• Hope (I’m still hoping and praying she can pull through this.)

Family/Team dynamics

• Patient/family conflicted within themselves; may want different things at different times
• Dysfunctional family system (family members unable to put the patient's needs/values/priorities above their own).
• Surrogate lack of ability (cognitive deficit, psychological/psychiatric trait/illness). In pediatrics, this can be conflict between what is in the best interest of a child vs. a caregiver or family.
• Consulting teams disagree about the optimal approach, putting the patient/family in the middle of the dispute.

Relationship between the Clinician and the Patient/Surrogate

• Lack of trust in the health care team/health care system.
• Past experiences where the patient has had a better outcome than predicted.
• Genuine value differences:
• Cultural/religious values concerning life, dying, and death.
• Clinician value of wanting to protect the patient from invasive, non-beneficial treatment while the family values wanting to prolong life no matter how much suffering it might entail.

All of these issues represent a degree of conflict and will need to be addressed before proceeding to set end-of-life goals. See Fast Facts #183,184 for additional discussion on managing conflict.

Debriefing Conflicts are stressful for all involved health professionals. It is helpful to debrief the process – what went well, what could have been improved, and – most importantly – addressing the emotional reaction and needs of the care team. See Fast Fact # 203 on managing clinician emotions.

References

1. Back AL, Arnold RM. Dealing with conflict in caring for the seriously ill. JAMA. 2005; 293:1374-1381.
2. Lazare A, Eisenthal S, Frank A. Clinician/Patient Relations II: Conflict and Negotiation. In: Lazare A, ed. Outpatient Psychiatry. Baltimore, MD: Williams and Wilkins; 1989.
3. Fisher R, Ury W. Getting to Yes: Negotiating Agreement Without Giving In. Boston, MA: Houghton-Mifflin; 1981.
4. Quill TE. Recognizing and adjusting to barriers in doctor-patient communication. Ann Intern Med. 1989; 111:51-57.

5. Back A, Arnold R, Tulsky J. Mastering communication with seriously ill patients: balancing honesty with empathy and hope. New York, NY: Cambridge University Press; 2009.

Author Affiliations: Medical College of Wisconsin, Milwaukee, WI (DEW); University of Rochester Medical Center, Rochester, NY (TEQ); University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, PA (RMA).

Fast Facts and Concepts are edited by Drew A. Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For more information write to: drosiell@mcw.edu. More information, as well as the complete set of Fast Facts, are available at EPERC: http://www.mcw.edu/eperc. Readers can comment on this publication at the Fast Facts and Concepts Discussion Blog (http://epercfastfacts.blogspot.com).

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Weissman DE, Quill TE, Arnold RM. The Family Meeting: Causes of Conflict. Fast Facts and Concepts. January 2010; 225. Available at: http://www.eperc.mcw.edu/fastfact/ff_225.htm.

Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.