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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
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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
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EEPPEECC
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SummarySummary
Resolving conflict leads to Resolving conflict leads to better outcomesbetter outcomes
Resolving conflict leads to Resolving conflict leads to better outcomesbetter outcomes