More information about text formats
I was interested to read the articles in this month’s journal exploring the difficulties of end of life decisions when parents and their doctors cannot agree.(1–3) These articles reflect the global media attention focused upon several recent tragic cases in the UK, where differences in view between parents and the clinical team led to confrontation and an unfolding tragedy in the public arena. Whilst all these articles describe the complexity they offer little in terms of solutions. Is it possible to prevent future cases from degenerating into public dispute, or is it an inevitable consequence of modern medicine? Have we advanced to a point where children that would have succumbed now live, and so the focus of care has shifted towards how they live rather than if they live or die?
At least part of the solution should be a shift in focus shift toward prevention of conflict in these high stakes clinical areas rather than finding a remedy once conflict has occurred. This is not just about being better at communicating with families. Conflict prevention will require cultural change, the identification of early warning signs and the use of mediation to facilitate communication between parents and doctors at an early stage.
Communication is not just about what we say, but about how we act and the social networks that we live and work in. It was interesting that there was also an article on Family Integrated Care in the same issue of the journal (4). Patel and colle...
Communication is not just about what we say, but about how we act and the social networks that we live and work in. It was interesting that there was also an article on Family Integrated Care in the same issue of the journal (4). Patel and colleagues describe a new way of working in intensive care medicine, where parents are integrated into the clinical team as primary caregivers. They describe how cultural changes to clinical practice enhance the wellbeing of parents and reduce length of stay of their new-borns. Parental integration will surely improve communication between parents and staff. It reduces barriers to effective communication and creates a shared problem rather than adopting sides.
Despite everyone’s best efforts, there will be times when dissatisfaction and conflict arise. To prevent communication breakdown we should identify risk factors within the situation that would lead to early intervention. Forbat et al identified three distinct phases of escalation in paediatric conflicts from mild, through, moderate to severe.(5) The mild stage focussed on conflict triggers, for example, the inappropriate use of language, conflicting messages given to parents by clinical staff, staff making assumptions about parents and a history of previous unresolved conflict. Training clinical staff to recognise conflict early and use mediation skills to de-escalate and resolve it is another intervention. Six month follow up of a cohort of staff trained in one tertiary children’s hospital reported that 57% of respondents had experienced conflict in the six months following the training. Of these, 91% reported that the training had enabled them to de-escalate the conflict.(6) Formal testing of a framework for the early recognition and management of conflicts between families and health professionals is being undertaken by four tertiary hospitals in the UK later this year.
Only after these foundations are in place, where parents are empowered as part of the clinical team, and an open and safe environment for communication already exists, that local hospital review panels and clinical ethics committees and the courts may be able to help when complex clinical decisions need to be considered. These panels should be introduced as part of the wider clinical team. Doctors and parents should approach them together as a united front to listen to their deliberations.
It is vital that we learn how to prevent these high-profile cases from occurring again. There are no winners or losers in these situations, only victims and casualties: parents whose chance of coping with bereavement has been broken, and a career curtailing event for the doctors and nurses who cared for them. When parents and doctors are in conflict, once sides have been drawn the battle is lost. Changing the way that we work with families, mediation as routine practice, and the early identification of the warning signs of conflict is the only way to prevent this from happening again.
1. Wallis C. When paediatricians and families can’t agree. Arch Dis Child. 2018 May;103(5):413–4.
2. Wheeler R. Response to “When paediatricians and families can”t agree’. Arch Dis Child. 2018 May;103(5):410–1.
3. Lagercrantz H. Observations on the case of Charlie Gard. Arch Dis Child. 2018 May;103(5):409–10.
4. Patel N, Ballantyne A, Bowker G, Weightman J, Weightman S, Helping Us Grow Group (HUGG). Family Integrated Care: changing the culture in the neonatal unit. Arch Dis Child. 2018 May;103(5):415–9.
5. Forbat L, Teuten B, Barclay S. Conflict escalation in paediatric services: findings from a qualitative study. Arch Dis Child. 2015 Aug;100(8):769–73.
6. Forbat L, Simons J, Sayer C, Davies M, Barclay S. Training paediatric healthcare staff in recognising, understanding and managing conflict with patients and families: findings from a survey on immediate and. Arch Dis Child. 2017 Mar;102(3):250–4.