1. Learning objectives to meet the goals of knowledge to practice:  Define the term family  Discuss issues of conflict which may interfere with advance care planning  Identify communication strategies to support the individual’s family Lakehead U N I V E R S I T Y

2. WHAT IS FAMILY?  in health care, the definition of family is broad and refers to the ‘family system’  those closest to the person in knowledge, care and affection  Biological family Related by blood Related by adoption  Family of acquisition Related by marriage/contract  Family of choice - a group of people who share common attitudes, interests, or goals and, frequently, live together Outside of the traditionally defined family May include friends Lakehead U N I V E R S I T Y

3. WHAT IS BEHIND THE SOURCE OF CONFLICT  Be aware of family dynamics at times of stress - avoid labelling  Conflict may arise in different situations and involve different people  Pressure to understand the severity of the illness, treatment options and making the ‘best’ decision  Contributing social, emotional, cultural and personal factors  Is there a subtext that underlies the words?  Are reactions unrelated to the immediate issue at hand? Lakehead U N I V E R S I T Y

4. THINGS TO CONSIDER Things to remember:  No two families are alike  Many families have long histories of troubled relationships  Avoid ‘taking sides’ – establish boundaries  Always attempt to foster communication and understanding among family members  Remain non-judgemental – resist giving advice  Resist imposing personal standards and values Lakehead U N I V E R S I T Y Stresses which may create conflict:  Intense feelings  Uncertainty  Old family conflicts  Changes in family roles  Economic difficulties  Past experiences with loss or death  Fluctuation from denial to acceptance

5. Consequences Resulting from Conflict Conflicts may result in:  Lack of treatment or over treatment  Lack of trust in health care providers & system  Loss of precious time  Emotional depletion  Increased stress  Complicated bereavement Lakehead U N I V E R S I T Y Difficult situations may include:  Not respecting advance directives (i.e. not willing to accept the person’s wishes)  Lack of agreement on care  Designated POA or SDM not local  Shared POA without congruency

6. KEEP IN MIND....  Don’t take it personally - anger is at the situation  Expect denial  Give appropriate information  Explore past methods of coping  Encourage discussions which provide reasoning behind the decisions  Recognize own limits  Utilize the expertise of other team members in helping with conflicts  Focus on the goal to make decisions that respect the person’s wishes, values and goals Lakehead U N I V E R S I T Y Is the reaction a result of  what is being said  the timing of what is being said  what is represented by what is being said

7. HEALTH CARE PROVIDERS IN CONFLICT WITH SDM’S BALANCED COMMUNICATION –NEGOTIATION- MEDIATION  Values & experiences of healthcare providers – awareness of impact on others (perceived power)  Resolution is the responsibility of health care providers  It is important for the entire health care team to show caring, respect, and support for the acting SDM in order to emphasize that they are working with him/her as part of the team  Show interest  Inquire about their well-being Lakehead U N I V E R S I T Y

8. Things to consider:  Is the environment conducive for discussion  SDM’s understanding of the situation  SDM’s fear of making the wrong decision  Guilt  Sense of abandonment  Responsibility for ‘killing’ their loved one  Broad range of reactions  Unique challenge of communicating emotionally laden material  What do you hear?  Clarify ambiguous statements  Listen in balance with speaking Lakehead U N I V E R S I T Y Explore the Bigger Picture Why did the conflict arise? Identify changes in behaviours of health care providers and the system

9.  Reflect on ways you could be contributing to conflict  Identify ways in which you can change your behaviour or make a conciliatory gesture  Avoid labelling i.e ‘dysfunctional family’  Try to understand the emotional meaning of the context of what is being said  Work towards being unbiased  Encourage self-awareness  Remember the importance of non-verbal communication  Recognize the cost of ignoring the problem Lakehead U N I V E R S I T Y Positive Conflict Resolution Note: family members may refuse to bring forth advance directives if they disagree with the contents or out of fear of losing their loved one when it is clear that imminent death is near  acknowledge their emotions  educate

10. COMMUNICATION: QUESTIONS TO ASK TO GET THE CONVERSATION STARTED WITH A SDM OR POA Lakehead U N I V E R S I T Y  What can the health care team do to help you and your loved one? Help us understand what your loved one would want if he/she could speak to us now.  What are some of the things that make life worth living for your loved one?  If your loved one were going to die soon, what are some of the personal things that would be important for her/him to take care of?  Do you and/or your loved one have religious or spiritual ways to get ready for death?  Are there heath problems that your loved one would think are worse than death, such as living with severe pain, with total physical dependency, or not being able to recognize or communicate with family and friends?

11. STEPS TOWARD RESOLUTION  Acknowledge the goals, values, beliefs and wishes of the person  Work towards positive communication strategies  Rely on strengths from members from the inter- disciplinary team (i.e. Pastoral care, social work)  Utilize structures within and external to the current setting – inter-organizational supports e.g. ethics committee, legal assistance, Public Trustee and Guardian, capacity assessor Lakehead U N I V E R S I T Y

12. The single biggest problem in communication is the illusion that it has taken place George Bernard Shaw

13. REFERENCES Centre for Education and Research on Aging & Health. (2008). Working with families. Thunder Bay: Lakehead University, 3.1-3.34. Educating Future Physicians in Palliative and End-of-Life Care (EFPPEC). (2008). Facilitating Advance Care Planning: An Interprofessional Educational Program: Curriculum Materials. Ottawa : EFPPEC, 42-50.