NURS 6914 Week 6 conflict resolution memo example

Memorandum

To: Interdisciplinary Care Team, Long-Term Care Unit

From: Palliative Care Nurse Practitioner

Date: Month Day, Year

Re: Proposed approach to the family conflict over Mrs. A.'s care after repeated aspiration pneumonia

Purpose

This memo proposes that the team treat the conflict among Mrs. A.'s three children as mainly a problem of unequal information, not of opposing values, and address it first with one shared information session for all three siblings. It also sets out when an ethics consultation would become appropriate.

Background

Mrs. A. is an 87-year-old resident with advanced Alzheimer disease. She says a few words at a time, depends on staff for every part of her day and has had three episodes of aspiration pneumonia in five months. Each time she was treated on the unit with antibiotics. Her durable power of attorney for health care names all three children to act jointly, sets no rule for breaking a tie and records no treatment preferences.

Her daughter visits every day, attended the last care conference and has heard the team explain that recurrent aspiration in advanced dementia is a sign of the final stage. Her older son lives abroad and receives updates by phone from his sister, which he says are "filtered." After each infection he calls the unit and demands that his mother be sent to the hospital. Her younger son, who had little contact with the family for years, has reappeared in the past month and says he wants "everything done." Staff describe feeling caught between the siblings, and the daughter is exhausted.

Analysis

The conflict looks like a disagreement about values, but the evidence suggests it is mainly about information. Only the daughter has heard the team's explanation directly. Research on the clinical course of advanced dementia shows that eating problems and pneumonia are common in its final stage and that burdensome interventions, including hospital transfers, are frequent in the last months of life (Mitchell et al., 2009). The older son may not know that, and the younger son has missed years of her decline.

Thomas and Kilmann (2007) sort responses to conflict by how hard a person pushes for their own aim and how far they work with others, which yields five modes, from competing and avoiding at the extremes to collaborating, accommodating and the middle ground of compromising. The older son is competing: assertive, focused on his position and uncooperative with his sister's account. The daughter has moved from collaborating to accommodating, giving way to avoid more calls and more conflict. The younger son may be competing partly out of guilt for his absence. Staff are avoiding, relaying messages rather than addressing the disagreement.

Family conflict at the end of life often reflects long histories, communication patterns and grief rather than the clinical decision alone, and it tends to ease when families receive consistent information and support (Kramer et al., 2006). Here, a shared understanding of her condition is the necessary first step.

It is also worth naming what the conflict is not. None of the siblings has said that their mother's life should be ended or prolonged at any cost for its own sake. Each is trying, in his or her own way, to be a good child: the daughter by sparing her mother further hospital stays, the older son by insisting nothing be missed from far away and the younger son by making up for lost years. Saying this aloud at the session may lower the temperature before any decision is discussed.

Recommendations

1. Confirm legal authority. The social worker will review the power of attorney with the facility's counsel to clarify how joint agents make decisions and what happens if they disagree.

2. Hold one information session for all three. The nurse practitioner and the unit's charge nurse will meet the siblings together, with the older son by video, to explain her condition, the meaning of repeated aspiration and the likely course. Hearing the same information at the same time removes the charge that it has been filtered.

3. Ask each sibling what their mother would want. After the information session, the conversation turns from what each child wants to what she valued. The daughter recalls her mother saying she never wanted to "live like Grandma did" in a nursing home. The sons may have their own memories. Substituted judgment shifts the question away from winning.

4. Offer a trial of options. If the siblings cannot agree, propose treating the next infection on the unit with a defined review point, rather than committing to or ruling out hospital transfer permanently.

5. Support the daughter. The social worker will meet with the daughter separately about her exhaustion and offer respite options.

6. Give staff one message. All staff will refer calls about treatment decisions to the nurse practitioner or the charge nurse, so the siblings hear one voice.

When to Request an Ethics Consultation

An ethics consultation would be appropriate if the siblings still disagree after the shared session and a discussion of their mother's values; if one sibling acts alone in a way that conflicts with the joint power of attorney; or if the team comes to believe that a requested intervention, such as repeated hospital transfer, is causing her suffering without benefit. The consultation would be requested as support for the family and team, not as a way to override the siblings.

Requested Action

Please approve the shared information session within the next week and the single point of contact for calls. I will coordinate scheduling with all three siblings, including the time difference for the older son.

References

Kramer, B. J., Boelk, A. Z., & Auer, C. (2006). Family conflict at the end of life: Lessons learned in a model program for vulnerable older adults. Journal of Palliative Medicine, 9(3), 791-801. https://doi.org/10.1089/jpm.2006.9.791

Mitchell, S. L., Teno, J. M., Kiely, D. K., Shaffer, M. L., Jones, R. N., Prigerson, H. G., Volicer, L., Givens, J. L., & Hamel, M. B. (2009). The clinical course of advanced dementia. New England Journal of Medicine, 361(16), 1529-1538. https://doi.org/10.1056/NEJMoa0902234

Thomas, K. W., & Kilmann, R. H. (2007). Thomas-Kilmann conflict mode instrument. CPP.