The EPEC-O Curriculum is produced by the EPECTM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

Education in Palliative and End-of-life Care - Oncology

The

ProjectEPEC-O

TM

EEPPEECC

OO

EEPPEECC

OO

Module 12Module 12

Conflict ResolutionConflict ResolutionModule 12Module 12

Conflict ResolutionConflict Resolution

EPEC – Oncology Education in Palliative and End-of-life Care – Oncology

EPEC – Oncology Education in Palliative and End-of-life Care – Oncology

Overall messageOverall message

Resolving conflict leads to Resolving conflict leads to better outcomesbetter outcomes

Resolving conflict leads to Resolving conflict leads to better outcomesbetter outcomes

ObjectivesObjectives

List factors that can lead to conflictList factors that can lead to conflict

Understand Understand

How to identify common factorsHow to identify common factors

How to communicate and negotiate to How to communicate and negotiate to resolve conflict directlyresolve conflict directly

The steps involved in fair processes to The steps involved in fair processes to resolve intractable conflictresolve intractable conflict

List factors that can lead to conflictList factors that can lead to conflict

Understand Understand

How to identify common factorsHow to identify common factors

How to communicate and negotiate to How to communicate and negotiate to resolve conflict directlyresolve conflict directly

The steps involved in fair processes to The steps involved in fair processes to resolve intractable conflictresolve intractable conflict

VideoVideo

Oncologists and conflictOncologists and conflict

Patients / families may be invested in Patients / families may be invested in interventionsinterventions

‘‘I insist on further therapy’I insist on further therapy’

Physicians / other professionals may Physicians / other professionals may be invested in interventionsbe invested in interventions

‘‘I want to give more therapy’I want to give more therapy’

Any party may perceive conflictAny party may perceive conflict

Patients / families may be invested in Patients / families may be invested in interventionsinterventions

‘‘I insist on further therapy’I insist on further therapy’

Physicians / other professionals may Physicians / other professionals may be invested in interventionsbe invested in interventions

‘‘I want to give more therapy’I want to give more therapy’

Any party may perceive conflictAny party may perceive conflict

Conflict over treatmentConflict over treatment

Unresolved conflicts lead to miseryUnresolved conflicts lead to misery

Most can be resolvedMost can be resolved

Try to resolve differencesTry to resolve differences

Support the patient / familySupport the patient / family

Base decisions onBase decisions on

Best evidence, informed consent, Best evidence, informed consent, advance care planning, goals of careadvance care planning, goals of care

Unresolved conflicts lead to miseryUnresolved conflicts lead to misery

Most can be resolvedMost can be resolved

Try to resolve differencesTry to resolve differences

Support the patient / familySupport the patient / family

Base decisions onBase decisions on

Best evidence, informed consent, Best evidence, informed consent, advance care planning, goals of careadvance care planning, goals of care

Root causesRoot causes

MisunderstandingMisunderstanding

ValuesValues

Personal factorsPersonal factors

Inappropriate decision-makerInappropriate decision-maker

MisunderstandingMisunderstanding

ValuesValues

Personal factorsPersonal factors

Inappropriate decision-makerInappropriate decision-maker

Misunderstanding of diagnosis / prognosisMisunderstanding of diagnosis / prognosis Underlying causesUnderlying causes

How to assessHow to assess

How to respondHow to respond

Underlying causesUnderlying causes

How to assessHow to assess

How to respondHow to respond

Misunderstanding: underlying causes . . .Misunderstanding: underlying causes . . . Doesn’t know the diagnosisDoesn’t know the diagnosis

Too much jargonToo much jargon

Different or conflicting information Different or conflicting information

Previous over-optimistic prognosisPrevious over-optimistic prognosis

Stressful environmentStressful environment

Doesn’t know the diagnosisDoesn’t know the diagnosis

Too much jargonToo much jargon

Different or conflicting information Different or conflicting information

Previous over-optimistic prognosisPrevious over-optimistic prognosis

Stressful environmentStressful environment

. . . Misunderstanding: underlying causes. . . Misunderstanding: underlying causes Sleep deprivationSleep deprivation

Emotional distress Emotional distress

Psychologically unprepared Psychologically unprepared

Inadequate cognitive abilityInadequate cognitive ability

Sleep deprivationSleep deprivation

Emotional distress Emotional distress

Psychologically unprepared Psychologically unprepared

Inadequate cognitive abilityInadequate cognitive ability

Types of conflicts Types of conflicts

Disagreement overDisagreement over

GoalsGoals

BenefitsBenefits

Disagreement overDisagreement over

GoalsGoals

BenefitsBenefits

Difference in valuesDifference in values

ReligiousReligious

MiraclesMiracles

Value of lifeValue of life

ReligiousReligious

MiraclesMiracles

Value of lifeValue of life

Personal factorsPersonal factors

DistrustDistrust

GuiltGuilt

GriefGrief

Intra-family issuesIntra-family issues

Secondary gainSecondary gain

Physician / nursePhysician / nurse

DistrustDistrust

GuiltGuilt

GriefGrief

Intra-family issuesIntra-family issues

Secondary gainSecondary gain

Physician / nursePhysician / nurse

Criteria for selection of surrogate decision-maker. . .Criteria for selection of surrogate decision-maker. . .

Patient’s stated preferencePatient’s stated preference

Legislated hierarchyLegislated hierarchy

Who is most likely to know what the Who is most likely to know what the patient would have wanted?patient would have wanted?

Patient’s stated preferencePatient’s stated preference

Legislated hierarchyLegislated hierarchy

Who is most likely to know what the Who is most likely to know what the patient would have wanted?patient would have wanted?

. . . Criteria for selection of surrogate decision-maker. . . Criteria for selection of surrogate decision-maker

Who is able to reflect the patient’s Who is able to reflect the patient’s best interest?best interest?

Does the surrogate have the Does the surrogate have the cognitive ability to make decisions?cognitive ability to make decisions?

Who is able to reflect the patient’s Who is able to reflect the patient’s best interest?best interest?

Does the surrogate have the Does the surrogate have the cognitive ability to make decisions?cognitive ability to make decisions?

A 7-step protocol to resolve conflict . . .A 7-step protocol to resolve conflict . . .

1.1. SettingSetting

2.2. PerceptionPerception

What is known?What is known?

3.3. InvitationInvitation

Explore hopes and expectationsExplore hopes and expectations

1.1. SettingSetting

2.2. PerceptionPerception

What is known?What is known?

3.3. InvitationInvitation

Explore hopes and expectationsExplore hopes and expectations

. . A 7-step protocol to resolve conflict. . A 7-step protocol to resolve conflict4.4. KnowledgeKnowledge

Attempt to resolve the conflictAttempt to resolve the conflict

5.5. EmotionEmotion

RespondRespond

6.6. SubsequentSubsequent

Make a plan and follow throughMake a plan and follow through

7.7. Reassess and revise regularlyReassess and revise regularly

4.4. KnowledgeKnowledge

Attempt to resolve the conflictAttempt to resolve the conflict

5.5. EmotionEmotion

RespondRespond

6.6. SubsequentSubsequent

Make a plan and follow throughMake a plan and follow through

7.7. Reassess and revise regularlyReassess and revise regularly

Misunderstanding: how to respond . . .Misunderstanding: how to respond . . . Choose a primary communicator Choose a primary communicator

Give information inGive information in

Small piecesSmall pieces

Multiple formatsMultiple formats

Use understandable language Use understandable language

Frequent repetition may be requiredFrequent repetition may be required

Choose a primary communicator Choose a primary communicator

Give information inGive information in

Small piecesSmall pieces

Multiple formatsMultiple formats

Use understandable language Use understandable language

Frequent repetition may be requiredFrequent repetition may be required

. . . Misunderstanding:how to respond. . . Misunderstanding:how to respond Assess understanding frequentlyAssess understanding frequently

Do not hedge to “provide hope”Do not hedge to “provide hope”

Encourage writing down questionsEncourage writing down questions

Provide supportProvide support

Involve other health care Involve other health care professionalsprofessionals

Assess understanding frequentlyAssess understanding frequently

Do not hedge to “provide hope”Do not hedge to “provide hope”

Encourage writing down questionsEncourage writing down questions

Provide supportProvide support

Involve other health care Involve other health care professionalsprofessionals

When conflict persistsWhen conflict persists

Seek assistanceSeek assistance

ConsultantsConsultants

External facilitatorExternal facilitator

Second opinionSecond opinion

Ethics committeeEthics committee

When the team is the source of When the team is the source of conflictconflict

Seek assistanceSeek assistance

ConsultantsConsultants

External facilitatorExternal facilitator

Second opinionSecond opinion

Ethics committeeEthics committee

When the team is the source of When the team is the source of conflictconflict

EEPPEECC

OO

EEPPEECC

OO

SummarySummary

Resolving conflict leads to Resolving conflict leads to better outcomesbetter outcomes

Resolving conflict leads to Resolving conflict leads to better outcomesbetter outcomes