1. The EPEC-O Curriculum is produced by the EPEC TM 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 Project EPEC-O TM

2. EPECEPECOOEPECEPECOOO EPECEPECOOEPECEPECOOO Module 12 Conflict Resolution Module 12 Conflict Resolution EPEC – Oncology Education in Palliative and End-of-life Care – Oncology

3. Overall message Resolving conflict leads to better outcomes

4. Objectives l List factors that can lead to conflict l Understand How to identify common factors How to communicate and negotiate to resolve conflict directly The steps involved in fair processes to resolve intractable conflict l List factors that can lead to conflict l Understand How to identify common factors How to communicate and negotiate to resolve conflict directly The steps involved in fair processes to resolve intractable conflict

5. Video

6. Oncologists and conflict l Patients / families may be invested in interventions ‘I insist on further therapy’ l Physicians / other professionals may be invested in interventions ‘I want to give more therapy’ l Any party may perceive conflict l Patients / families may be invested in interventions ‘I insist on further therapy’ l Physicians / other professionals may be invested in interventions ‘I want to give more therapy’ l Any party may perceive conflict

7. Conflict over treatment l Unresolved conflicts lead to misery Most can be resolved l Try to resolve differences l Support the patient / family l Base decisions on Best evidence, informed consent, advance care planning, goals of care l Unresolved conflicts lead to misery Most can be resolved l Try to resolve differences l Support the patient / family l Base decisions on Best evidence, informed consent, advance care planning, goals of care

8. Root causes l Misunderstanding l Values l Personal factors l Inappropriate decision-maker l Misunderstanding l Values l Personal factors l Inappropriate decision-maker

9. Misunderstanding of diagnosis / prognosis l Underlying causes l How to assess l How to respond l Underlying causes l How to assess l How to respond

10. Misunderstanding: underlying causes... l Doesn’t know the diagnosis l Too much jargon l Different or conflicting information l Previous over-optimistic prognosis l Stressful environment l Doesn’t know the diagnosis l Too much jargon l Different or conflicting information l Previous over-optimistic prognosis l Stressful environment

11. ... Misunderstanding: underlying causes l Sleep deprivation l Emotional distress l Psychologically unprepared l Inadequate cognitive ability l Sleep deprivation l Emotional distress l Psychologically unprepared l Inadequate cognitive ability

12. Types of conflicts l Disagreement over GoalsBenefits GoalsBenefits

13. Difference in values l Religious l Miracles l Value of life l Religious l Miracles l Value of life

14. Personal factors l Distrust l Guilt l Grief l Intra-family issues l Secondary gain l Physician / nurse l Distrust l Guilt l Grief l Intra-family issues l Secondary gain l Physician / nurse

15. Criteria for selection of surrogate decision-maker... l Patient’s stated preference l Legislated hierarchy l Who is most likely to know what the patient would have wanted? l Patient’s stated preference l Legislated hierarchy l Who is most likely to know what the patient would have wanted?

16. ... Criteria for selection of surrogate decision-maker l Who is able to reflect the patient’s best interest? l Does the surrogate have the cognitive ability to make decisions? l Who is able to reflect the patient’s best interest? l Does the surrogate have the cognitive ability to make decisions?

17. A 7-step protocol to resolve conflict... 1.Setting 2.Perception What is known? What is known? 3.Invitation Explore hopes and expectations Explore hopes and expectations 1.Setting 2.Perception What is known? What is known? 3.Invitation Explore hopes and expectations Explore hopes and expectations

18. .. A 7-step protocol to resolve conflict 4.Knowledge Attempt to resolve the conflict Attempt to resolve the conflict 5.Emotion Respond Respond 6.Subsequent Make a plan and follow through Make a plan and follow through 7.Reassess and revise regularly 4.Knowledge Attempt to resolve the conflict Attempt to resolve the conflict 5.Emotion Respond Respond 6.Subsequent Make a plan and follow through Make a plan and follow through 7.Reassess and revise regularly

19. Misunderstanding: how to respond... l Choose a primary communicator l Give information in Small pieces Multiple formats l Use understandable language l Frequent repetition may be required l Choose a primary communicator l Give information in Small pieces Multiple formats l Use understandable language l Frequent repetition may be required

20. ... Misunderstanding: how to respond l Assess understanding frequently l Do not hedge to “provide hope” l Encourage writing down questions l Provide support l Involve other health care professionals l Assess understanding frequently l Do not hedge to “provide hope” l Encourage writing down questions l Provide support l Involve other health care professionals

21. When conflict persists l Seek assistance Consultants External facilitator Second opinion Ethics committee l When the team is the source of conflict l Seek assistance Consultants External facilitator Second opinion Ethics committee l When the team is the source of conflict

22. EPECEPECOOEPECEPECOOO EPECEPECOOEPECEPECOOO Summary Resolving conflict leads to better outcomes