The nature of conflict in palliative care: A qualitative exploration of the experiences of staff and family members

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Abstract

Objectives

Conflict is a significant and recurring problem in healthcare. This study aimed to understand staff and relatives’ perspectives on the characteristics of conflict and serious disagreement in adult palliative care, including triggers, risk factors and the impact on themselves and clinical care.

Methods

Qualitative study of 25 staff and seven bereaved relatives using individual interviews, recruited from a multidisciplinary specialist palliative care setting in Australia. Data were analysed thematically.

Results

Communication was frequently cited as a cause of conflict. Further, different understandings regarding disease process, syringe drivers and providing nutrition/hydration caused conflict. Staff applied empathy to moderate their responses to conflict. Relatives’ reactions to conflict followed a trend of anger/frustration followed by explanations or justifications of the conflict. Relatives identified systemic rather than interpersonal issues as triggering conflict.

Conclusions

The data illustrate connections with conflict literature in other clinical areas, but also points of convergence such as the compassion shown by both families and staff, and the identification of systemic rather than always individual causes.

Practice implications

Family meetings may fruitfully be applied to prevent and de-escalate conflict. Clinical audits may be useful to identify and provide support to families where there may be unresolved conflict impacting grief process.

Introduction

Conflict is a significant and recurring problem in health care [1], [2], [3], [4], [5], [6]. Commonly identified causes/triggers of conflict include breakdown in communication [4], relatives’ involvement in decision-making [7], patient and family mistrust of the healthcare system [8], religious beliefs and cultural differences about treatment goals [4], [9], [10], refusal of treatment [9] and misunderstanding of prognosis [11]. A recent integrative review of conflict identified a lack of emotional intelligence alongside systemic organisational issues as key antecedents [12].

The triadic healthcare relationships (involving patient–relative–healthcare team) [13] in settings where conflict has been documented adds complexity to the dynamic and increases the potential for disagreement and conflict. The combination of very sick patients, high mortality, multiple specialities and a frequent need for decisions on complex matters are recognised as factors in conflict [14]. Consequently adult palliative care, which exhibits these characteristics, is likely to experience conflict.

Although conflict in palliative care is a recognised phenomenon, there has been little primary research, and the few papers reporting conflict are based on anecdotal clinical reports [11]. One exception to this paucity of data is a recent study comparing intensivist and specialist palliative care clinicians’ responses to conflict [15]. The authors identified that specialist palliative care clinicians used language which was less task-oriented and slightly more focussed on relationship building. Palliative care is intended as a holistic, multidisciplinary approach to relieve suffering, for both patient and families [16]. Therefore, attending to suffering within the clinical relationships is particularly pertinent.

Little has been established through robust empirical work about the causes and outcomes of conflict in specialist palliative care. This study sought to understand staff and relatives’ perspectives on the characteristics of conflict and disagreement in adult palliative care, including triggers, risk factors and the impact on themselves and clinical care. The study focused solely on conflict between staff and patients/relatives, rather than intra-staff or intra-familial conflict.

Section snippets

Methods

A qualitative inductive design was applied using semi-structured individual interviews.

Results

25 staff members and seven relatives participated in the study. Table 1 illustrates participant role. Staff length of service in specialist palliative care services (including experience prior to the current service) ranged from five months to twenty years, with a mean duration of 10 years (mode: 12 years, median: 11years). Participants were mainly female (n = 21/25 staff, 84%) and worked in both in-patient and out-patient contexts (n = 7 and n = 13 respectively), with five staff working across both

Discussion

While dictionaries define conflict as active disagreement, these data indicate the emotional undertow of conflict in palliative care. Communication difficulties underpinned many conflict scenarios. Although communication issues varied, the majority centred on difficulties in reaching a shared understanding of palliative care or goals of care. Communication difficulties often plague clinical practice, and dominate patient experience feedback, despite a considerable body of work in communication

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflict of interest

None of the authors have any conflicts to declare.

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