Background     Conflicts about medical care occur frequently at the end of life.  These conflicts threaten therapeutic relationships and lead to patient, healthcare provider, and family dissatisfaction.  Conflict between the patient/family and physician may arise from simple factual misunderstandings about medical care.  Frequently, however, conflict is driven by a patient’s or family’s emotions such as feeling unheard or ignored, as well as having goals that conflict those of the medical team.  In these instances, attempting to convince a patient or family through providing additional medical information will not work.  This Fast Fact provides an alternative approach to conflict resolution based on understanding a patient’s or family’s story, attending to their emotions, and establishing shared goals.  A subsequent Fast Fact (#184) will focus on conflict resolution employing the techniques of Principled Negotiation.

1.  Learn the patient’s and family’s story

• Begin discussions with a genuine curiosity to learn what they perceive to be the course of events during the illness.
• Explore the context of the patient’s illness narrative with attention paid to their relationships with doctors, their sources of medical information, and their life goals (see Fast Fact #26)
• Avoid presenting agenda items for a meeting that are defined by the medical team’s priorities.  Instead, focus on the patient’s and family’s concerns.
• If a patient or family is asking for treatment against the recommendation of the medical team, focus on the context of the request.  Have they been let down by the medical system in the past?  Have they found that others in their family have benefited from the treatment they request? 
• Find out how they want information presented to them.  Do they want specific benefits and risks?  Do they want written information? 

2.  Attend to emotions

• Conflict can cause strong emotions in healthcare providers including guilt, anger, and resentment.  Acknowledge these emotions to yourself and other professionals, but strive to prevent them from interfering with your interactions with the patient and family.
• Patient and family emotions such as grief, disappointment, and anger are to be expected in these situations.  Compassionately acknowledge and address these emotions as they arise, and allow the patient and family to express what is making a situation frustrating for them (see Fast Facts #29, #59).  When people are emotionally stressed, they may have trouble cognitively processing information.  Empathically attending to emotions often allows a patient or family to move on to understanding medical information.
• If a family is focusing on what they believe was an error in care, be transparent about where a mistake may have been made (see Fast Facts #194, 195).  Apologize.  Even if it was not an error, one can acknowledge how frustrating the situation is.  Saying “I can tell that this situation is frustrating for you,” is not an admission of error—it is empathic.

3.  Establish shared goals for treatment

• Use the patient’s core values as a foundation for developing a treatment plan. “I would like to know more about your mother and what her values have been during her life.”
• Ask about a patient’s goals including what they would want if they were dying or if there were no curative treatments available for their condition. 
• When there are requests for ineffectual treatment, describe instead where the medical team can make a difference for the patient, in relation to their goals.  “Please correct me if I’m wrong, but it sounds like your mother really values her independence and freedom from being in pain.  Let’s try to figure out how we can best help her achieve these goals.”

Summary    Providing medical information to patients and families may seem at first to be the most natural approach to resolving conflict.  Addressing the underlying roots of conflict will have a longer lasting effect.  The above approach emphasizes resolving conflict through finding mutual trust and shared goals between physicians, patients, and families.

Reference

Stone D, Patton B, Heen S. Difficult Conversations: How to Discuss What Matters Most. New York, NY: Penguin Books; 1999.

Version History:  Originally published July 2007.  Version re-copy-edited in May 2009; then again July 2015.