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Conflict and compromise: How clinicians can improve end-of-life conversations

connect-316638_1280Disjointed communication between families and clinicians can, in the worst cases, turn end-of-life care decisions into something like a combative presidential debate. Both sides want only the best for the patient. So why do so many conversations end in frustration?

Robert Arnold, MD, the medical director for University of Pittsburgh Medical Center Palliative and Supportive Institute, said that ultimately the conflict escalates because each side thinks the problem lies with the other party.

Arnold spoke at Stanford recently for the Center for Biomedical Ethics' 26th annual Jonathan J. King Lectureship. King, PhD, an artificial intelligence researcher who died of cancer in 1991, advocated for compassionate and humane patient care, inspired by his experience as a cancer patient. Organizers screened a video of King speaking to set the context for the lecture: "Empathize. Put yourself in your patient’s shoes as much as you can.”

In his lecture, Arnold addressed myths and misconceptions about conflict between patients and care providers and offered strategies for clinicians to reframe how they approach family conversations.

He said that conflict stems from doing the “talk, talk, talk” to such an extent that no one listens enough, and that everyone involved prioritizes their own values over building trust. Difficult conversations, according to Arnold, can be broken down into three categories: "fact" (breaking bad news about a diagnosis and  providing status updates), "feelings" (fielding emotional responses and providing feedback), and "identity" (affirming roles in care). Clinicians get into conflict by treating all three types of difficult conversations solely with cognitive reasoning, undervaluing the importance of empathy and personal relationships.

Bridging these communication gaps is as simple as imagining you are speaking to your partner or teenage son or daughter, Arnold said. He urged both parties to openly express feelings of empathy and compassion and to acknowledge different values. Clinicians, Arnold advised, should ask questions, speak at the family’s level of understanding and encourage families to ask questions. The doctors need to reconnect with their own emotions and values, he said, because the relationship with the family is as important as the decision made with the family. Clinicians also need to be honest about the possibilities and limits of medicine, Arnold said.

These communication skills are teachable, and they should be increasingly incorporated into medical school curricula, Arnold said. “We need to say as a society that having good conversations is as important as having a high tech ICU.”

Until both parties improve their ability to communicate and connect, Jonathan King’s messages will continue provide needed guidance, Arnold said. As King once said, "Stop trying to convince, and start understanding."

Previously: Flipping roles and using design-thinking principles to improve communication,  End-of-life discussions the focus of PBS pieceStanford doctor on a mission to empower patients to talk about end-of-life issues and The importance of human connection as part of the patient experience
Photo by PublicDomainPictures

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