Conflict at the End of Life: When Dying is Preceded by Conflict

This is a very difficult place for most people: the intersection of grief, end-of-life decision making, quality of life at the end of one’s life, and conflicted emotions. Every family situation is different of course, but often there are feelings of guilt, resentment, anticipatory grief and despair that can overwhelm the more typical means of communication with others.   Several people I know in the hospice field have mentioned there is often a high amount of conflict as the dying person gets closer to the end of life.  I recently read Dr. Kiran Gupta’s article entitled “Hostile family member keeps doctors from focusing on patient.”    and it was quite an eye-opener about the level of conflict that those providing medical care to terminally ill or dying patients can be dragged into.

I’m sure there aren’t many of us who could imagine that this type of thing could happen in our family.  Sadly, I know of many hospice staff members who report that a patient’s impending death ramps up emotionality on many fronts and often leads to emotional, verbal and sometimes physical outbursts of violence among family members and loved ones.

This is a common issue in the broader context of family and intergenerational conflicts: who “owns” the conflict?  Sometimes it is difficult to identify the person “responsible” for managing or resolving the conflict , especially when the conflict is longstanding, ongoing and otherwise an “orphan,” such that no family member will own or take any responsibility for the existence of the conflict or a person’s share in it.  If a person is in hospice care, the medical providers or other hospice staff may somehow find themselves saddled with responsibility for the conflict because they are providing health care services, which is often the preferred focus of family members, who may not be prepared to work through the underlying conflict.

Here are some tips:

  • name the nature of the conflict – listen actively, reflecting back to check for comprehension;
  • consider the present costs of the conflict – in terms of the ill person’s limited time and the need of family members to attend to that person and get along with each other in the time remaining;
  • identify the causes of conflict in end-of-life care (include many differences of opinions relating to meaning of life, quality of life , standards for end of life care, age differences, poor or unproductive communication skills, and social, cultural and educational differences ;
  • ask whether the conflict and interactions can be managed successfully when and where possible; and
  • how to engage a third party mediator for resolving the conflicts stemming from end-of-life care

Simply naming the conflict – noting its existence and identifying its nature can be a huge leap from a stagnant conflict to a process of simplifying how it can be managed productively or resolved.    It is important to keep in mind that end of life questions and decisions involve high stakes outcomes and are morally complex and tend to invoke high levels of emotion, which are often expressed as reactions to a threat and often there is not time or emotional space for reflective decision making.  This can lead to a very difficult position – here are a few questions to consider if you or someone you know is struggling with situation:

  1. Ask yourself: how do I contribute to this conflict?
  2. How can I shift my behavior to enable an easier means of reconciliation?
  3. Can I get past my emotional baggage I bring to the conflict and focus on making the end of life situation the best it can be for my loved one?

If you find yourself honestly answering #3 and it is not a resounding “yes,” getting a third party involved might be helpful.   You may want to talk with a third party about preliminary aspects of a facilitation or mediation in this setting by:

  • estimating the cost of pretending there is no conflict (avoidance); outcome of  confrontational approach (likely to escalate);
  • considering the impact of the conflict on other decision making contexts, – financial, medical, emotional, etc.;
  • honestly and openly examining the role of the conflict and how it impacts the person affected – are they expected to take sides or manage a conflict given their declining heath;
  • looking behind the anger to unmask the underlying fear, rejection, remorse, etc (remembering that mediation is not therapy); and
  • deciding who will participate in the mediation

The process of sharing the responsibility for the conflict means you can share responsibility for managing and resolving it, and if you participate in mediation, you can also explore shared solutions.  The beauty of having a third party facilitate the process is that all interested persons can participate, and there isn’t one that has to “manage” how the others interact, at the expense of getting their own voice heard.

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