New advice seeks to prevent conflict between parents and paediatricians – UK study

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Conflict can arise between health professionals and the parents of children not only where there is disagreement on the withdrawal or withholding of life sustaining treatment but also in more general routine care. A new paper for paediatricians and other health professionals suggests ways to help reduce conflict.

While disagreement with the management of a child’s healthcare is rare, when it does happen it can have profound effects on the child, their family and health professionals.

The number of children living with complex and/or life limiting conditions is continuing to rise as advanced forms of life sustaining treatment become available. There is also a large amount of information online about innovative but unproven treatments for serious illnesses which increases the likelihood of conflict in paediatric practice.

A new paper published in the Archives of Disease in Childhood, “Achieving Consensus: advice for paediatricians and other health professionals on prevention, recognition and management of conflict in paediatric practice” suggests ways for paediatric clinicians to help identify and reduce disharmony while maintaining the child’s best interest.

Lead author and Registrar of the Royal College of Paediatrics and Child Health (RCPCH), Dr Mike Linney, said: “health professionals have to make decisions every day about treatment: some routine and some more emotive and complex. These decisions, which always have the child’s best interests at heart, are made alongside the family, but in a very small number of cases, doctors and families disagree. Conflict is physically and mentally damaging for everyone involved, and in recent years, as cases are propelled into the public domain, further complexity is added to an already sensitive and stressful situation.”

This new document, for the first time, brings together practices covering prevention, recognition and management of situations where conflict exists, to support healthcare professionals either prevent disharmony, or manage it. It suggests:

Preventative management

  • Avoiding giving inappropriate expectations to families
  • Using palliative care teams early, not just for end of life care but when treatment options are being discussed
  • Providing access to psychological support to families but also health professionals involved with the child’s care
  • Assigning a Lead Clinician to be responsible for the overall care of the child, including to act as a liaison between family and medical teams, to help ensure messages given to families are clear and consistent, and acknowledging a family’s understanding and expectations and if misunderstanding develops

Identifying conflict

  • Clinical teams must be able to spot the early signs of conflict including: communication breakdown, parents and health professionals avoiding each other, parents feeling they need to oversee or review every aspect of care

Early management

  • Seeking expert ethical and legal advice and considering early involvement of mediation services
     

“Due to changing shift patterns, families can see several different professionals, and as a result sometimes receive conflicting information – this is contributory factor of conflict. Assigning a Lead Clinician will be a very effective way of preventing these disputes and so too will instructing mediation services much earlier,” Dr Linney said

The paper’s advice also provides information on conflict escalation, seeking a second opinion from an independent expert or arranging behavioural and communication advice.

Dominic Wilkinson, an ethicist and co-author of the RCPCH advice, said, “this document is a recognition by professionals that there is a problem with these cases—of intense disagreement—and they are not going to go away.

The College’s advice, which is based on evidence from clinicians, parents, parent advocates, and ethicists, said that clinical staff should be careful not to give conflicting information to parents and should avoid giving families unrealistic expectations of clinical outcomes.

Wilkinson said, “I think it can be very hard for a family to accept in this day and age, with all of the things that we read in the news about new therapies and the state of science, that actually there might be nothing more that medicine can do to help.”

He said that, although it was a struggle and took time, parents would often come to terms with the idea that the best thing to do for their child was not to continue treatment.

“Sometimes those expectations remain, and the family just cannot accept [that there is no treatment]—and the question is, what do you do? Part of this document is about saying sometimes doctors need extra help,” said Wilkinson.

The RCPCH said that an Australian paediatric conflict management framework, developed in conjunction with the paediatric oncology department at Perth’s Princess Margaret Hospital, helps recognise and de-escalate conflict in paediatric practice. In the pilot program incidents had dropped by 64%. The framework had also been tested at four UK hospital sites, with the findings being assessed to see whether it could be helpful in the entire UK healthcare setting.
 

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