Dealing with Conflict / Communication / Nurses / Health Professionals

Nurses play an important role in recognising and addressing conflict in palliative care

Related Resources

palliAGED Evidence Summary - Family Conflict
palliAGED Practice Points - Family Conflict

Many patients and families are under significant strain. Clear communication can provide reassurance and guidance. This can help improve quality of life while they are approaching death and help them make decisions on complex matters.

Good communication can avoid confusion or misunderstanding and guide realistic expectations. This ultimately improves the quality of care.

However, conflict can occur between:

patients and their family
patients and clinicians
family members, especially when the patient cannot speak for themself
between relatives and clinicians.

This may occur when there is disagreement about the most appropriate management plan or whether a person’s expectations of care are being met.

Conflict can arise within a care team when:

there is disagreement or perceived disagreement on role or responsibility
there is disagreement on goals of care, priorities of care or chosen option of care
a clinical observation or recommendation is not heeded by other members of the team
there is lack of information sharing in planning and coordination of care.

In any situation, conflict can arise from:

misunderstandings, poor communication, or a breakdown in communication
different understandings of the disease process and the goals of care
a person’s perceived role or responsibility
a mismatch between the expected type and level of care and the care provided/received
a lack of shared understanding of the dying process or where the patient is in this process
feeling unprepared for deterioration and death
perceived lack of support or a sense of being overwhelmed
cultural and language differences that affect understandings and perceived norms
uncertainty as to who is coordinating care.

Communication tips

Identify and recognise the disagreement or conflict as early as possible and make other members of the care team aware if it is likely to affect the person’s care.

Verbal cues:

You might suspect or notice a person’s irritation or anger in what they say or their tone of voice.
A person may clearly express anger, dissatisfaction, frustration.

Non-verbal cues:

You might notice body language like eye-rolling, a sideways glance or a person withdrawing from interactions.
A person may stiffen or tense in the presence of a certain person or people.

What you can do

For conflict with a person receiving care or conflict within a family, you can:

Communicate clearly and with sensitivity to families and staff when you recognise deterioration or signs that indicate that a person is dying. This gives the opportunity for the family to be prepared for the approaching death.
Allow time for the person and family and other members of the team to come to terms with the approaching deterioration and death.
Find a time and a place where the discussion can be held in private with minimal or no distractions or interruptions.
Listen to the person, giving them your full attention.
Rather than focusing on facts or information alone, acknowledge the person’s emotion (e.g. anger, disappointment, shock, frustration, fear, grief) with empathy as this can help resolve the conflict.
Identify what the conflict is about, and discuss possible options as a shared interest
'I believe that there’s been a misunderstanding in terms of… If we were to … do you think that that could improve the situation?'

Talk openly with the person to try to reach a mutual understanding.
'Could we list a couple of options, then spend a minute talking about the pros and cons?'

Align the conversation with the person’s values and preferences.

'If […] were able to talk to us, what do you think they would want us to know?'

Recognise limitations (e.g. you are unlikely to resolve longstanding family dysfunction).

In certain circumstances, it may be helpful to have a family member, preferably nominated by the person with advanced illness, who can communicate with the rest of the family and make decisions.

When the conflict is unresolved and is affecting a person’s care, consider:

arranging a second opinion for the family
a skilled communicator to facilitate a family meeting or case conference
a patient advocate to help resolve issues on behalf of the person or the family.

For conflict within the care team, you can:

Acknowledge the conflict and reflect on the situation and what you believe the conflict is.
Find a time and a place where the discussion can be held in private with minimal or no distractions or interruptions.
Prepare information that is relevant to the issue.
Listen to the person, giving then your full attention.
Rather than focussing on facts or information alone, acknowledge the person’s emotion (e.g. anger, disappointment, shock, frustration, fear, grief) with empathy as this can help resolve the conflict.
Identify what the conflict is about, and discuss possible options as a shared interest
'I believe that there’s been a misunderstanding in terms of… If we were to …, do you think that that could improve the situation?'

Talk openly with the person to try to reach a mutual understanding.
'Could we list a couple of options, then spend a minute talking about the pros and cons?'

Align the conversation with the patient’s values and preferences, the scope of practice of the people involved.
'It seems to me that we are both interested in [the patient’s well-being].'

If you agree on a resolution, you may also look at a way of checking that any agreed steps are underway and mutually acceptable
'Perhaps we should consider [action] [timeline] as a sign of whether we are going in the right direction?'

Not every conflict has a solution that everyone feels good about. Sometimes you may agree that you have a different point of view and that the conversation can be taken up again on respectful terms in the interest of a person’s care.

This information was drawn from the following resources:

Back AL, Arnold RM. Dealing with conflict in caring for the seriously ill: "it was just out of the question". JAMA. 2005 Mar 16;293(11):1374-81. doi: 10.1001/jama.293.11.1374.
Dahlin CM, Wittenberg E. Communication in palliative care: An essential competency for nurses [Internet]. In: Ferrell BR, Paice JA, editors. Oxford textbook of palliative nursing. 5th ed. Oxford: Oxford University Press; 2019. [cited 2022 Sep 23].
End-of-Life Essentials. End-of-Life Essentials Education [Internet]. 2022 [updated 2022 Oct 4; cited 2022 Oct 10].
François K, Lobb E, Barclay S, Forbat L. The nature of conflict in palliative care: A qualitative exploration of the experiences of staff and family members. Patient Educ Couns. 2017 Aug;100(8):1459-1465. doi: 10.1016/j.pec.2017.02.019. Epub 2017 Feb 24.
LeBlanc TW, Tulsky J. Discussing goals of care [Internet]. 2022 [updated 2022 Jul 11; cited 2022 Oct 10].
LeBlanc TW, Tulsky J. Communicationwith the patient and family [internet]. In: Cherny N, Fallon M, Kaasa S, Portenoy RK, Currow DC, editors. Oxford Textbook of Palliative Medicine. 6th ed. Oxford, UK: Oxford University Press; 2021. [cited 2022 May 9].
Lichtenthal WG, Kissane DW. The management of family conflict in palliative care. Prog Palliat Care. 2008 Feb 1;16(1):39-45. doi: 10.1179/096992608x296914.
VitalTalk. Defusing Conflicts: Moving the conversation forward [Internet]. 2019. [cited 2022 Sep 26].