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.

Why Would I Want to Use an Elder/Probate Mediator for My Family’s Dispute?

How is your relationship with your siblings now that you must make plans for an aging or ailing parent who needs your help?  If you are facing this challenge – you are definitely not alone!  Lots of life events can shake up our worlds, many of them are anticipated and some unanticipated, but nothing has quite the same effect as having to deal with difficulties relating to an aging or ailing parent.  There is no preparation for this either – as life events go, this situation simply didn’t exist until recently because we didn’t have the longevity we have now which coupled with medical advancements and healthier lifestyles  make for an ever-expanding number.  Couple this with the number of baby boomers coming up on retirement age, and it’s quite impressive.  Your odds of being a caregiver at some point in your life are quite high, and so are the chances for conflict in that relationship.   Many of the difficulties among siblings stemming from dealing with an aging parent’s care   can be managed through effective communication (if that is possible and practiced), but taking care of an aging or ailing parent can be scary for many of us because it is a reminder of our own mortality  and often puts a history of sibling dysfunction into the forefront,  and this can be a toxic combination for siblings who may want to be pulling together for their parent when they find themselves unable to do so.

How do you and your siblings get along now, how have you fared in your adult relationships with each other, and is dealing with an aging or ailing parent putting a serious strain on the relationship?  This strain will obviously affect your ability to care for your parent, as well as how you take care of yourself and your own family

How do you find a mediator?  You can look on the internet of course for someone who has experience in not just mediation but also the substantive area of elder care – so they are familiar with the types of issues (financial, emotional, medical) as well as the legal context for the disputes (appropriate use of durable power of attorney, also guardianship and conservatorship issues).  The AARP recently published an article about how to choose an elder mediator   I liked how this article referred to mediators as “peacemakers,” as that is essentially the role of a mediator in this context, and it recognizes that adult child caregiving is usually fraught with conflict, as it often involves a difficult situation where siblings may be inattentive or disagree about a course of action to assist an aging, ill or frail parent.

In Colorado, mediators are not required to be licensed – so it’s an especially good idea to do some background checking about the mediator’s background and experience.  Holding oneself out as an “elder care mediator” is something most anyone could do, so you may want to confirm that a mediator has completed a 40 hour mediation training course (at minimum) and has some experience in elder care or probate disputes.    Here’s a simple roadmap for charting your course with siblings:

  1. What is fair?
  2. Who will decide?
  3. How will we work together?
  4. Don’t underestimate the transformational power of compassion; and
  5. Get help if you need it!

Happy trails!

What is the “Promise” of Elder Mediation?

The New York Times has a column entitled “The New Old Age” and in a post from today by Paula Span entitled “Care by Consensus” some of the challenges of getting a workable plan for caring for an elder who has no family members to assist in the process.  Many of us deal with these issues with siblings, children, aunts, uncles and neighbors involved.  Sometimes this involves effectively sharing  the burden of caring for an again or frail family member, and others it looks more like a power struggle, outright warfare or a means of unearthing long-standing ill feelings of “mommy always loved you best.”  This is discussed in a March 13, 2012, article in Forbes by Carolyn Rosenblatt titled “Aging Parents, Embattled Kids: Can You Find Pain Relief?” Read it here.

As an elder and probate mediator, I found the ABA’s December 2010 Bifocal issue’s article by Ellie Crosby Lanier, “What Is Quality in Elder Care Mediation and Why Should Elder Law Advocates Care?” a bit more insightful as to available options.

Elder/Probate mediation requires a special set of skills. Many of us who are professionally trained mediators believe in the promise of this approach to conflict resolution, even though adoption and endorsement of elder/probate mediation is slow in coming.  Elder mediation is used in other countries, and perhaps the most informative and exhaustive work about its progress has been put together by The Center for Social Gerontology.  You can find the voluminous document here.

What kinds of disputes is mediation particularly well-suited in the elder/probate context?

  • Decisions about care management/ living arrangements
  • Productively managing independence (driving, autonomy)
  • Concerns about loss of financial control and responsibility
  • Adult children and “fairness” among siblings, expectation of heirship
  • Facilitating capacity and managing incapacity
  • Trusts and estates disputes
  • Medical decision making and responsibility

Just to name a few.  These disputes don’t need to simmer before they boil.  But sometimes a health crisis or an elder’s failure to plan can bring certain latent situations to active conflict.  Often the person who suffers most as a result is the elder, because they may (or may not ) be aware of the conflict, and its potential to wreak havoc.

I think part of an attorney’s informed consent is an exploration of the options – from the interest-based peace-making options to the no-holds-barred litigation scenario.  The challenge is that many of my colleagues know little about the peacemaking or mediation option, so it is a legitimate question to ask “what it would look like,” along with “how do I find a good elder mediator?” Read “A Referee for Family Disputes,” by Anne Tergesen, from the Feb. 5, 2011, Wall Street Journal. Lots of folks have commented on it. Check it out.