Aims Disagreements over treatment decisions in paediatrics and in particular withholding or withdrawal of life sustaining care, are costly, time consuming and traumatic for all involved. This project seeks to identify if such conflicts follow an identifiable path in order to provide clinicians with a practical model for recognising and managing them.
Method Participants were recruited through hospitals and hospices. Extreme-case sampling was used to identify 46 individuals who had direct experience of conflict at the interface of acute and palliative care including physical assault and court proceedings. 9 parents, 18 consultants, 9 nursing staff, 2 medical trainees, 2 lawyers, 3 religious leaders, and 1 ethicist were interviewed individually or in pairs. A further 100 professionals and families contributed to identifying trigger points for conflicts in general paediatrics, through a wide range of teaching sessions in hospitals and hospices. Interviews and triggers were transcribed and analysed for common themes and trends. Ethics approval was obtained and the study funded by a grant from the Department of Health.
Results Data analysis identified key warning signs for the escalation of conflicts. Clearly identifiable events and behaviours by both clinicians and families were grouped into Green, Amber and Red stages of escalation. Further study of the data together with an analysis of Glasl's 9 Stage Model of Conflict Escalation suggested that differing methods of conflict management would be appropriate at each stage. Thus events in the Green Zone could be managed by those within the team, conflicts within the Amber Zone might be resolved by an independent third party, for example a mediator, and conflict in the Red Zone would be more likely to require Police or Judicial Intervention.
Conclusion The Conflict Pathway provides clinicians working on the front line with a practical, evidence-based toolkit to identify the warning signs in such conflicts. By proactive management of conflicts within the Green Zone early resolution may be achieved. By managing conflicts in the Amber and Red Zones in a timely manner, external help can be sought before the mental and physical safety of clinicians and families is put at risk.
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