Thank you
Retirement Research Foundation
Family Conflict in the
Nursing Home Setting
For support for this webinar series.
Betty J. Kramer, PhD, MSSW
University of Wisconsin-Madison
School of Social Work
Deirdre Downes, LCSW
Jewish Home Lifecare
Deirdre Downes, LCSW is
the Corporate Director of
Social Work Initiatives at
Jewish Home Lifecare in
New York and has worked
in the field of aging for over
twenty years. She received
her undergraduate degree
from Barnard College and
her master’s degree from
Hunter College School of
Social Work. She is
currently a Ph.D candidate
at City University of New
York Graduate Center.
Dr. Betty J. Kramer is a Professor of Social
Work at the University of WisconsinMadison. She is a nationally recognized
gerontology researcher and educator
whose research has strengthened
understanding of male caregivers,
caregiving gains, transitions in the
caregiving career, the nature of end-oflife caregiving, and family conflict at the
end of life. She is co-author of Living
through Loss: Interventions across the
Life-Span (2006) and Men as Caregivers
(2002) and recipient of the National
Hospice and Palliative Care Organization
Distinguished Researcher Award (2008).
3
Overview
4
What is Family?
• Defining terms.
• Rationale for understanding
family conflict.
• A research agenda on the
causes and consequences.
• Implications for “best
practices”
• Case study in the nursing
home setting
• “People in a committed relationship
from which they shape a sense of
identity”
(Kissane & Bloch, 2002, p. 2)
• Whoever its members say it is
(Kissane & Bloch, 2002, p. 48)
5
6
1
Why is Family Conflict
Important to Understand?
What is family conflict?
Clinical guidelines mandate
“Interpersonal tension or
struggle among two or
more persons (within the
family) whose opinions,
values, needs or
expectations are opposing
or incompatible”
(Kramer et al., 2006, p. 794)
7
Families intimately involved in:
(Hospice Patients Alliance, 2011; National
Consensus Project for Quality Palliative Care, 2009)
8
Impact of Illness on Family Functioning
•Care planning
•Decision making
• Communication
problems increase as
illnesses progress
• When conflict present,
proxy decision makers
less likely to make
decisions consistent
with elder’s wishes.
(Zhang & Siminoff, 2003)
• Illness severity predicts
higher levels of family
strain
(Parkes et al., 2011)
(Sales, Schulz & Biegel, 1992)
9
10
Conflict Exacerbates Suffering
Conflict Common & Matters
• At end of life – 35% - 57%
• Of Patient
(Boelk & Kramer, 2012; Kramer et al., 2006, 2010b).
–95% of Bio-ethics
consults = conflict
• “What matters most in EOL”
(Neveloff-Dubler, 2005)
– Unresolved issues/conflicts
– In top 4 (out of 28) of importance
among seriously ill patients
–Longer tx side-effects
(Kim & Morrow, 2003)
–Aggressive tx - nursing
home
Heyland et al. 2006)
(Lopez, 2009)
11
12
2
Conflict Exacerbates Suffering
Professionals Struggle
• Report feeling:
– ill prepared to address
conflict
• Of Family Members
– CG burden & depression
(Heru & Ryan, 2006; Strawbridge & Wallhagen, 1991)
(Back & Arnold 2005; King & Quill 2006)
– Complicated grief
–less successful addressing
care needs when conflict
present
(Kissane et al., 1996b; Kramer et al., 2010b)
(Kramer & Yonker, 2011)
13
What We Need to Better Understand:
A Recent Research Agenda
14
Hospice Study
(Boelk & Kramer, 2012)
• Mixed Method Case study
• Designed to replicate & extend
Elder Care study to:
• What is the nature of
family conflict at end of
life (what is it about)?
– Advance theory
– Examine correlates & predictors of
conflict
– Hospice setting
– Gain both professional and family
members perspectives
• What precipitates or
contributes to conflict?
• What are the
consequences?
15
Methods
16
Methods continued
• Mixed Methods
• Study Setting
– Non-profit hospice
– Serving 6 county area
– Central Wisconsin
–10 Focus Groups
–161 Family Caregiver Surveys
–15 Family Caregiver Interviews
17
18
3
Topics of Family Disagreements
Results
Presence of Family Conflict
in 161 admissions
100
• Caregiving
• The patient’s condition
• Treatments &
procedures
• Medication use
• Life-sustaining
measures
• Enrollment decisions
• Location of care
90
80
70
n = 97; (57%)
60
50
40
Presence of Prior conflict;
30
20
10
n=77 (48%)
0
Not Present
Present
• Post-death decisions
• Family roles &
responsibilities
• Family involvement
• Finances & estate
• Communication
• Spirituality
• Coping
19
20
Explanatory Matrix of Family Conflict
Family
Context
Conditions
Contributing
factors
Conflict
Consequences
(Boelk & Kramer, 2012)
Think about how relevant
these various examples are
to conflict you witness in
the nursing home setting
21
FAMILY CONTEXT
• Historical relationship
patterns
• Family involvement in care
• Family demands & resources
• Family structure
• Substance use, abuse,
dependency
• Advance care planning &
promises made
• Faith traditions & belief
systems
22
Illustration
Historical Relationship Patterns –
My dad always hated me, …never gave me
anything but kicks in the ass or a hit in the
face…he told me once I was garbage, … I’d
always be garbage. You don’t know how many
times I often thought, “garbage girl is taking care
of you now dad!”…There was sexual abuse in the
family that my dad did toward me … and he
started in on my sister…to this day I can hardly
stand to be in the same room alone with him…but
you got to …step up when you’re needed.
23
24
4
CONTRIBUTING FACTORS
CONDITIONS
Decline in Health Status and Functioning
Death Anxiety Difficulty
Integrating
Death
Awareness
Acute medical crisis
Elevated frailty
Admission into Hospice/Death Awareness
Absent Family Members “Coming out of the
Woodwork”
25
26
Contributing Factors continued
Contributing Factors continued
Incongruent
Perceptions of
Health Status,
Needs &
Preferences
Efforts to
Assert &/or
Maintain
Control
27
Contributing Factors continued
Communication
Constraints
28
Contributing Factors continued
Efforts to Seek
Resolution
29
30
5
Contributing Factors continued
Contributing Factors continued
Role
Expectations &
Obligations
Family Vying for
Estate &/or
Position
31
32
Consequences continued
CONSEQUENCES
Restricted or
delayed care
planning or
implementation
Patient wishes
and/or quality of
care jeopardized
33
Consequences continued
34
Consequences continued
Increased
Patient, Family,
and/or Team
Distress
Diminished
Support for
Patient and/or
Caregiver
35
36
6
Consequences continued
Implications for Best Practices
Severed Family
Relationships
37
Best Practices – Consider
all Phases of Conflict Reduction
Phase
Definition
Conflict
Monitoring and/or
Prevention intervening to stabilize
a potential conflict
before it escalates
Conflict
Minimizing the
Manescalation of conflict
agement
Conflict
Resolution
Encouraging
reconciliation of
differences
Tasks
Detecting warning signs.
Initiating activities that address
contributing factors to avert
conflict
Peace keeping.
Identify triggering events.
Promptly address, eliminate or
resolve issues that trigger
conflict - set rules or limits.
Peace building.
Negotiate agreements
Mediation
38
Best Practice: Encourage Advance
Planning Conversations
– May prevent or manage conflict arising from
incongruent perceptions of preferences
– Minimizes risk of overtreatment
• Without conversations, surrogates “tend to make errors of
over-treatment, rather than under-treatment” (Moorman, Carr,
p.812; Wenger, Shugarman & Wilkinson, 2008).
39
40
Best Practice: Family Assessment
Best Practice:
Routine Admissions Screening
• Genograms – Mapping the family
• Identify “Families at Risk”
to:
– Determine extent to which
conflict:
• Already exists
• Is amenable to change
• Whether family desires
intervention
– Determine potential for
contributing factors to arise
41
42
7
Family Relationship Index
“Family Conflict at the End-of-Life” scale
(developed by B. J. Kramer)
Developed by Moos and Moos
(1974); modified and adapted
(Kissane & Bloch, 2002).
TRUE
FALSE
1. Family members really help and support one another
As you think about the decisions that you and your family are facing
regarding your care (or the care of ____________), please answer the
following questions:
2. Family members often keep their feelings to themselves.
3. We fight a lot in our family.
4. We often seem to be killing time at home.
Please check one answer box per question.
5. We say anything we want to around the home.
6. Family members rarely become openly angry.
How much do any family members…
7. We put a lot of energy into what we do at home.
8. It is hard to ‘blow off steam’ at home without upsetting somebody.
Not
at all
A little
bit
Some- Quite a
Very much
what
bit
a.
Disagree or argue with one another?





b.
Feel resentment toward one another?





Feel anger toward one anther?





Insult or yell at one another?





44
9. Family members sometimes get so angry they throw things.
10. There is a feeling of togetherness in our family.
12. We tell each other about our personal problems.
13. Family members hardly ever lose their tempers
c.
Scoring Rules:
Cohesiveness = 1 True + 4 False + 7 True + 10 True.
Expressiveness = 2 False + 5 True + 8 False + 11 True
Absent Conflict = 3 False + 6 True + 9 False + 12 True
FRI = cohesiveness + expressiveness + absent conflict scores.
43
Best Practice: Engage & Disseminate
Information to “Identified Family”
d.
Family Member Quotes
• Don’t assume family
members are
communicating
• Offspring differ
significantly from their
parents in perceptions
of family
communication
“Nobody has reached out to her…and we don’t understand
why…They could have reached out to a sibling who is
disengaged…she won’t talk to us...”
“I think it would be nice if maybe, like [the social
worker]…calling the other kids, and saying “hey, how are
you doing? Is there anything you wanna talk about?”
Because I don’t know if they would go and initiate it
themselves.”
(Kissane et al., 1994)
45
Best Practice:
Routine Family Conferences
46
Family Member Quote
“Of the interventions
identified…, the
importance of regular,
properly managed
family conferences or
meetings as a mean of
preventing and
managing EOL conflict
has the strongest
evidence base”
“Ongoing family meetings would probably be
a good idea, because then people talk, and
sometimes you need a mediator to bring
these things out….one on one just doesn’t
help the whole workings of it.”
(CRELS project, 2010, p. 27)
47
48
8
Facilitating the Family Conference:
The Process
Purpose of Family Conferences
Provide and Share Information
Excellent Resource:
“Family Meetings in
Palliative Care:
Multidisciplinary Clinical
Practice Guidelines”
a. Medical updates
b. Educate - correct misinformation
c. Get everyone on “same page”
Facilitate Decision-Making &
Planning
(See Hudson, Quinn, O’Hanlon & Aranda, 2008)
Address Affective Needs
a. Normalize feelings
b. Provide opportunities for
expression and reconciliation
49
Elements for Successful Conferences
•
•
•
•
•
•
•
•
•
Pre-planning
Common goals & agenda confirmed
Realistic expectations
Key team members present
Designated chairperson
Awareness of the family struggle
Use of emotionally supportive behaviors
Inclusion of all significant family members
Careful communication
50
Best Practice: Adhere to General
Principles of Conflict Management
• Maintain flexibility
• Maintain neutrality, transparency and
professionalism
• Avoid splitting
• Avoid demonizing
• Set necessary limits
(Atkinson, Stewart & Gardner, 1980; Curtis et al., 2002; Dugan, 1995; Fineberg, Kawashima, & Asch, 2011; Hudson
et al., 2008; Schmall & Pratt, 1989)
(see Holst, Lundgren, Olsen & Ishoy, 2009, p. 40)
51
Best Practice: Principled Negotiation
for Conflict Resolution
52
Principled Negotiation cont…
Four Principles
3. Invent options for mutual gain (proposing solutions)
1. Separate the people (i.e., relationship issues,
perceptions, emotions, communication problems)
from the problem (i.e., substantive problems).
2. Focus on interests, not positions (reframing
problems).
4. Outlining/using objective criteria when available (e.g.,
research evidence, position statements regarding care
standards)
“Your position is something you have decided
upon. Your interests are what caused you to so
decide” (Fisher & Ury, 1992, p. 42).
53
54
9
Common Nursing Home Family Conflicts
•
•
•
•
•
Nursing Home Case Study
Admission / Discharge Processes
Conflicts with Spouse or Family Members
End of Life Issues / Decision-Making
Financial Decisions / Medicaid Application
Conflicts between NH staff and family
55
56
Key References
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Key References
Ambuel B and Weissman DE. Moderating an end-of-life family conference, 2nd Edition. Fast Facts and Concepts. August 2005; 16.
Available at: http://www.eperc.mcw.edu/fastfact/ff_016.htm.
Arnold, E.M>, Artin, K.A., Griffith, D., Person, J.L., & Graham, K.G. (2006). Unmet needs at the end of life : Perceptions of Hospice Social
Workers. Journal of Social Work in End-of-Life and Palliative Care, 2(4), 61-83.
Back, A.L. & Arnold, R.M. (2005). Dealing with conflict in caring for the seriously ill: It was just out of the question.” Journal of the
American Medical Association, 293(11), 1374-1381.
Bloche, M. G., (2005). Managing conflict at the end of life. The New England Journal of Medicine, 352, 2371-2373.
Boelk, A.Z. & Kramer, B.J. (2012). “Advancing theory of family conflict at the end of life: A hospice case study.” Journal of Pain and
Symptom Management, 44, 655-670.
Bowman, K. (2000). “Conflict Resolution”, Ian Anderson Continuing Education Program in End-of-Life Care, Module 9. Available at:
http://www.cme.utoronto.ca/endoflife/Modules/CONFLICT%20RESOLUTION%20MODULE.pdf
Fineberg, I.C., Kawashima, M., & Asch, S.M. (2011). Communication with families facing life-threatening illness: A research based model
for family conferences. Journal of Palliative Medicine, 14, 421-427.
Fisher, R. & Ury, W. (1983). Getting to yes: Negotiating agreement without giving in. New York: Penguin Books. (a useful summary of
key points of this book may be found at http://www.colorado.edu/conflict/peace/example/fish7513.htm).
Gentry, D.B. (2001). Resolving middle-age sibling conflict regarding parent care. Conflict Resolution Quarterly, 19, 31-47.
Hammes, B. & Briggs, L. (2007). Respecting Choices Advance Care Planning Facilitator’s Manual. Gunderson Lutheran Medical
Foundation, Inc.
Holst, L., Lundgren, M., Olsen, L., & Ishøy, T. (2009). Dire deadlines: Coping with dysfunctional family dynamics in an end-of-life care
setting. International Journal of Palliative Nursing, 15(1), 34-39-41.
Hospice Patients Alliance (2011). Dealing with families in conflict: Hospice staff roles in protecting patient and family interests.
Retrieved January 20, 2011 from www.hospicepatients.org/hospic78.html.
Hocker, J. & Wilmot, W.W. (2005) Interpersonal conflict (7th Ed). New York, NY: McGraw Hill Company.
Hudson, P., Quinn, K., O’Hanlon, B., & Aranda, S. (2008). Family meetings in palliative care: Multidisciplinary clinical practice guidelines.
BioMedicalCentral Journal, 7:12: doi:10.1186/1472-684X7-12
Kendall A, Arnold R. Conflict Resolution I: Careful Communication. Fast Facts and Concepts. July 2007; 183. Available at:
http://www.eperc.mcw.edu/fastfact/ff_183.htm.
Kendall A, Arnold R. Conflict Resolution II: Principled Negotiation. Fast Facts and Concepts. July 2007; 184. Available at:
http://www.eperc.mcw.edu/fastfact/ff_184.htm.
57
King, D.A. & Quill, T. (2006). Working with families in palliative care: One size does not fit all. Journal of Palliative Medicine, 9, 704-715.
•
•
•
•
•
•
•
•
•
•
•
•
•
Kissane, D.W. (1994). Grief and the family. In S. Bloch, J. Hafner, E. Harari & G. I. Szmukler, (Eds.) The Family in clinical psychiatry. Oxford:
Oxford University Press.
Kissane, D.W. Kissane, D.W., & Bloch, S. (2002). Family focused grief therapy. New York, NY: Open University Press.
Kissane, D. W. Bloch, S., Dowe, D.L., Snyder, R.D., Onghena, P., McKenzie, D.P., & Wallace, C.S. (1996a). The Melbourne family grief study, II:
Psychosocial morbidity and grief in bereaved familei;s. American Journal of Psychiatry, 153: 650-658.
Kissane, D. W. Bloch, S., Onghena, P., McKenzie, D.P., Snyder, R.D., & Dowe, D.L. (1996b). The Melbourne family grief study, II: Psychosocial
morbidity and grief in bereaved families. American Journal of Psychiatry, 153: 659-666.
Kramer, B. J., Kavanaugh, M., Trentham-Dietz, A., Walsh, M. & Yonker, J.A.. (2010a). “Complicated Grief in Caregivers of Persons with Lung
Cancer: The Role of Family Conflict, Intrapsychic Strains and Hospice Utilization..” OMEGA: Journal of Death and Dying, 62, 201-220.
Kramer, B.J., Kavanaugh, M., Trentham-Dietz, A., Walsh, M., & Yonker, J.A. (2010b). Predictors of family conflict at the end of life: The
experience of spouses and adult children of persons with lung cancer. The Gerontologist, 50, 215-225. [available online in 2009,
doi:10.1093/geront/gnp121].
Kramer, B.J. & Yonker, J.A. (2011) “Perceived Success in Addressing End-of-Life Care Needs of Low-Income Elders and their Families: What’s
Family Conflict Got to do with it?” Journal of Pain and Symptom Management, 41, 35-48.
Lopez, R.P. (2007). Suffering and dying nursing home residents: Nurses’ perceptions of the role of family members. Journal of Hospice &
Palliative Nursing, 9(3), 141-149.
Moorman, S.M., & Carr, D. (2008). Spouses’ effectiveness as end-of-life heath care surrogates: Accuracy, uncertainty, and errors of
overtreatment or undertreatment. The Gerontologist, 48(6), 811-819.
Moos, R.H. & Moos, B.S. (1981). Family Environment Scale Manual. Stanford, CA: Consulting Psychologists Press.
Neveloff-Dubler, N.. (2005). “Conflict and consensus at the end of life. Improving end of life care: Why has it been so difficult? Hastings
Center Report, Special Report 35, S19-S25.
Nugent, W.R., (2001). “Mediation techniques for persons in disputes.” In H. E. Briggs, & K. Corcoran (Eds), Social work practice: Treating
common client problems. (pp. 303-323). Chicago, IL: Lyceum Books Inc.
Vernooij-Dassen, M., Joling, K., Hout, H.V., & MIttleman, M.S. (2010). The process of family-centered counseling for caregivers of persons
with dementia: Barriers, facilitators and benefits. International Psychogeriatrics, 22, 769-777.
58
Comments?
Please type your question or comment
in the “Q & A” box (right side)
59
10