Background     When conflicts about medical care persist despite gaining mutual trust and a deep understanding of goals (see Fast Fact #183), it may be effective to use principled negotiation.  Principled negotiation is an approach to resolving conflict that avoids power struggles and unwanted compromises.  The following is an illustration of the steps that are involved.  Within each step, we will refer to a case example:  a family who is requesting artificial feeding against medical advice for their father who is dying from end-stage dementia. 

1.  Separate people from the problem.  Identify the fundamental problem, separating that from individuals’—on both sides—intentions and culpability.  

• The problem is not that the family members are “in denial” that their loved one is dying or “uneducated” when they do not hear the medical team’s recommendations.
• The problem is not that the family is acting out their frustration by making unreasonable demands.
• Nor is the problem that the medical team and hospital are trying to withhold treatment from the patient or “giving up” on him.
• The problem is that the patient is dying, no longer able to eat properly, and that artificial nutrition does not improve quality or quantity of life in this situation.

2.  Focus on interests.  Listen to requests and demands but try to look into underlying interests.  In addition, express the intentions and goals of the medical team.

• The family wants what is best for the patient. Their intent may be to provide comfort and to build up the patient’s strength, and to prevent a painful starvation. 
• The medical team wants to provide the best medical care for the patient.  Their intent may be to avoid an intervention that has no clear benefit for the patient, may cause harm, and may not have been desired by the patient.

3.  Invent solutions.  Avoid contrasting different philosophies of medical care.  Instead, propose a plan of care that meets a family’s expectations without detracting from good medical care.  Consideration could be given to:

• Meeting the family’s goals of providing food by allowing for the patient to taste home cooked meals.
• A short trial of tube-feeding with the plan to continue only if the overall quality of life for the patient improves.
• A trial of attentive oral feeding with a plan to reconsider tube feeding if the patient appears to be hungry or otherwise suffering. 
• Solutions that do not promote mutual interests are:  placing a feeding tube without a plan to measure its success or failure at meeting a goal, arranging for another medical team to take over the patient’s care, or referring the case to an ethics committee. 

4.  Outline objective criteria.  If a time trial is being pursued, agree upon what the deciding factors would be in determining a trial’s success.  Provide objective information to substantiate medical recommendations.

• Establish signs of improvement or worsening such as functional ability, weight, ability to interact, and level of consciousness.
• Establish criteria for harm such as infections, restraint or sedative use, hospitalizations or emergency department visits.
• Consider providing publications from organizations that advocate for patients and families, and are not associated with physicians or hospitals.
• Provide opinions or guidance from individuals outside of the conflict.  These could include social workers, case managers, chaplains, or therapists. 

References

1. Fisher R, Ury W.  Getting to Yes: Negotiating Agreement Without Giving In.  New York, NY: Penguin Books; 1992.
2. King DA, Quill T. Working with families in palliative care: one size does not fit all. J Pall Med. 2006; 9(3):704-715.

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