People are often surprised to learn there is potential for conflict when a loved one is in hospice. Unfortunately, many disputes do not cease when people are at or near death. On the contrary, folks can become even more entrenched in their positions at that particular time of life. As a person lays dying, most would assume families would be able to put aside their differences and work to peacefully coexist, if only for the sake of their dying family member. Sadly, that is often not the case. When a loved one is near the end of their life, the landscape is rife with emotion such as grief, guilt, and fear of the unknown. In addition, also present are a sense of helplessness and loss of control. At this difficult time, when people are at their most vulnerable, they often lash out at someone else, either another family member or a member of the hospice team. As a hospice nurse relates, “unresolved conflicts from years or even decades before may arise again in the face of these differences, not only erupting but intensifying.” Cathy Truehart, The Miracle of Hospice: A Personal Journey of a Hospice Nurse, Balboa Press, 102 (2012). In his book, Strong in the Broken Places, author Richard Cohen explains “{it} should make anyone wonder how common this kind of conflict is. Fighting in the family feels safer than taking on a dread disease. Fear and helplessness combine explosively. Old issues detonate at the most vulnerable moment {and it}… puts families under siege.” Richard M. Cohen, Strong at the Broken Places: Voices of Illness, a Chorus of Hope, HarperCollins, 48 (2008).
I recently took a course sponsored by the National Hospice and Palliative Care Organization called, “Managing Conflict in the Workplace.” Though the course is designed primarily for hospice managers, it is open to any member of the NHPC organization. I have been a hospice volunteer for more than ten years and I have seen first hand how emotions and grief can take over in an already desperate situation. I enrolled in the course to gain some insight into the day-to-day activities of hospice managers, as they pertain to conflicts, in order to help train staff, to coach, or to mediate disputes in that forum. There were about a dozen people in this on-line class and most were experienced hospice managers in facilities located all over the country. They represented hospices both large and small, for-profit and not-for-profit, and most agreed they were frustrated, saying they spend about “75% of their time managing disputes.”
So where is this “in-house” conflict coming from and why do these disputes arise? Many conflicts erupt between staff members, who, each wanting what is best for the patient and family, often come from different backgrounds or cultures, and disagree on how to best achieve that goal. There is often conflict between family members, siblings usually, who typically revert to their places in the family hierachy and think they know what is best for Mom or Dad at the end of their life. Family dynamics play a huge part in these conflicts and bad feelings usually do not change or improve when siblings age; people often just get louder and more entrenched. Childhood animosities and perceived slights bubble to the surface in times of strife. In their book, Mom Always Liked You Best, the authors say, “the real miracle of family life is that we are ever able to resolve a major family transition. Many barriers exist that keep us from having productive conversations…it is a long list: lack of trust, poor communication, entrenched patterns, emotional triggers and their responses” just to name a few. Kardasis, Larsen, et al, Mom Always Liked You Best: A Guide For Resolving Family Feuds, Inheritance Battles and Elder Care Crises, Agreement Resources, LLC, 45 (2011). Old habits die hard even at the end of life and siblings never forget how to push each others “conflict” buttons.
Another set of disputes often arises between the family and the hospice itself. This may include difficulties between one family member and a particular staff member(s) or between the entire family and the hospice administration. Sometimes staff refers to a family as “difficult” when the family wants some kind of something that the hospice will not or cannot supply and will not take no for an answer. This might include requests such as, “how come Mom can’t get some special treatment/medication or why can’t the nurse come every day or stay for a shift?” Many of these disputes center on demands that are not met due to either Medicare rules or unreasonable expectations on the part of the family. One of the myths and expectations that must be dispelled early on is that hospice provides at-home care 24/7. In reality, while hospice is on call 24/7 and provides nursing care or specialized services when needed, it is the family or paid care-givers that must fill the gap unless patient care is provided in a facility, such as a nursing home, or an inpatient hospice. Many families assume once hospice is on board, the family’s work is done. Unfortunately, if the patient remains at home, the hard reality is that a family member[s] or paid care giver[s] has to attend to the dying loved one for the many hours that hospice does not cover.
A possible solution to these end-of-life conflicts is mediation. The hospice conflict class offered tools for managers to help them establish a “dispute resolution process.” Without a defined process there is confusion and chaos. It is far easier to help resolve disputes if you have a road map to navigate the rough road ahead. Whether the disputes involve families or co-workers, all of the managers in the class agreed that in the future they would develop dispute resolution protocols and let the process guide them through these types of disputes.
As with any mediation, the mediator or manager has to separate interests from positions and let everyone at the table have a voice, all within a safe setting. Also key is to deal with the underlying emotions and dig into why and how the parties feel the way they do. I have discovered that resolutions are often hiding below the emotions and until those emotions are recognized and dealt with, the conflict will stretch out, fester longer, and the parties will never be satisfied with the outcome.
In guiding families through end-of-life conflicts, the mediator cannot hope to change the family dynamics or resolve decades-old sibling rivalries, but with patience and perseverance, perhaps the siblings’ commonalities can help them compromise to forge an acceptable agreement for the benefit of their loved one. Ira Byock describes healing a family at end of life. “Even at the very end of life, healing a relationship can transform the history of a family; {when} there is, nothing left unsaid or undone… these end-of-life decisions create opportunities for new experiences and discoveries that range from the fairly mundane to the frankly extraordinary.” Ira Byock, Dying Well: Peace and Possibilities at End of Life, Riverhead Books, p.53 (1997).
The mediator can and should be part of the hospice team helping patients, families, and team members foster healing relationships to bring peace during the final days of a person’s life.
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