Navigating Conflict with Families Gordon J. Wood, MD, MSCI, FAAHPM Winter Workshop, Coleman Palliative Medicine Training Program February 28, 2014 With thanks to Bob Arnold, Elizabeth Weinstein and Jonathan Adler.
This talk will help you: Recognize conflict Describe a 3 step approach to dealing with conflict Describe skills/techniques to help when conflict occurs Ask before telling NURSE emotions Explore identity issues
Recognize conflict What are signs of conflict between the medical team and a family?
Recognize conflict early Circular conversations Body language Sarcasm, criticism Own feelings of unease, threat, anger, frustration, withdrawal etc Rx: Notice, mentally step back, and pause
When people do not do what we want, what do we do? Seek to convince and persuade And if that doesn t work? Argue Blame Give up and walk away
How to deal with conflict: Three steps 1. Understand the conflict: Create a Learning Conversation 2. Find common ground 3. Devise a strategy addressing these issues
Step 1: Understand the conflict Their stuff Our stuff Facts Facts Emotions Emotions Identity Identity
First of 4 Questions to Ask yourself: Why is this otherwise well meaning person reacting in this challenging way?
The Differential Diagnosis: Three More Questions Facts: What is their story? Feelings: What are the feelings here? Identity: What does this mean about me/them?
Facts: An Anatomy of Error and Distortion Assumptions I am right you are wrong: If there are factual disagreements both are reality! False Consensus: one s views are more common than they really are Naïve Realism: if only they would hear the (my) truth they will become rational, reasonable and agree with me Repetition Wins: if I just say it one more time, they ll come around to my perspective
Facts - Learn their story : I d like to understand: can you tell me more about what you have been told about what is happening What are you hoping can be accomplished? Then listen
Pearl: What and How? vs Why? Why do you want your mother to have another course of chemo? Compare with What do you hope will happen if your mother has another course of chemo?
Feelings Emotions in Conflict Love Anger Fear Guilt Sadness Denial
How do I attend to feelings? NURSE Naming Understanding Respecting Supporting Exploring
Identity What does this mean about them? A check-in is often all that is needed We ve been talking a lot about your Dad but this is serious stuff. How are you doing with all of this? How is it affecting your life? What does this all mean for you? When you think about your job as your Dad s decision-maker, what s the most important thing in your mind?
Step 2: Find a common ground Summarize your understanding and perceptions of their understanding and check if it is correct Find shared understanding/meaning Patient s comfort Following the patient s wishes Family s peace with the decision-making process
Step 3: Devise a strategy addressing these issues Give them time Time-limited trial Hope for the best and plan for the worst
If there are irreconcilable differences Follow the family s wishes with a harm-reduction strategy Acknowledge the family s values and philosophy Stop regularly discussing goals of care Address the medical team s moral distress by: Communicating reasoning Finding patient-centered goals to feel good about Continue to exercise clinical judgment in what is offered Consider an ethics consultation
Pearls The and not but approach I can see the homeopathy is really important to you for your pain but I think the morphine would help too. I can see the homeopathy is really important to you for your pain and I think the morphine would help too. Focus on what can be done Emphasize that you hope the patient will improve Check in with the family Wish and we statements Take on decision-making burden
Pitfalls Don t try to convince the family that they are wrong Don t ask the family what they want to do Don t forget to address all three layers of the conversation
There are 2 sides to every conversation When a patient is getting to you, ask yourself these questions: Why? (3 levels) What kind of doctor does this patient need? What kind of doctor can I be for this person?
Conclusion Recognize conflict early Seek to understand their side: facts, emotions and identity issues Find shared common ground and purpose Devise a strategy Reflect on your role in the conflict
References Stone, D., B. Patton, et al. (1999). Difficult conversations. New York, Penguin. Back, Arnold Tulsky. Mastering communication with seriously ill patients. Cambridge University Press 2009