Shay Jacobson, RN, MA, NMG, LNCC, CNLCP
Martha Kern

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Families fight.

Some are loud and combustible, while others have slow-simmering feuds and long-standing resentments. There are spats, and there are wars.

Conflicts tend to erupt around holidays and other occasions that bring family members into the same airspace. When the occasion involves the failing health of a parent, family conflict can impact the patient, the care they receive and those who do their best to provide it.

The deteriorating health of a parent is a stressful situation. For many, this is new and unwelcome terrain. Adult children are called upon to make major decisions – and quickly – about treatments and placements and home care, all things they may know little about. The family is tired and, with time, burned out. Throughout the ordeal, all concerned are trying to keep their own lives on track. No wonder everyone is irritated, no wonder siblings are fighting.

What Lies Beneath
Of course, there is usually much more fanning the flames of conflict than the stress of the moment. Just below the surface of the present-day argument may rest any of a number of unspoken tensions:

Old Family Hostilities:
From “Mom liked you best” to “You always got away with everything”, a wide range of old grudges, rivalries and hostilities may bubble up as the family grapples with new and sometimes harsh realities. Siblings may resent what they see as ancient patterns continuing into current circumstances, stirring up buried feelings about fairness or their position in the family pecking order.

Who’s in Charge?:
In the midst of a health care crisis it often surfaces that Mom has named a Power of Attorney, or structured a trust in a particular way, and one family member is believed to have more power, influence or “favor” than another. This can set up the formation of factions in the family, and revive old resentments about past circumstances where this same sibling was perceived to hold some advantage.

Blended Families:
When Dad becomes ill, the children from his first marriage may work hard to unseat the second wife from a role of influence, control, or financial benefit. If there are two sets of children from two marriages, who will be at Dad’s beside and who has he chosen to lead and decide? Clearly, these are situations already primed for conflict and waiting to explode.

Mental Illness:
If the parent has struggled with mental illness over the course of his/her adulthood, there may be resentment and weariness in the family unit, even emotional damage, from years of cyclical instability. This can cause what appears to be indifference among adult children when, in fact, they may be trying to maintain some distance from the parent to avoid further emotional pain.

Prior Abuse:
When we meet a family in the midst of a medical crisis, we have no way of knowing what the history in that family might be. Children who are estranged or seemingly disengaged from the parent may have suffered abuse from Mom or Dad, or may have grown up in an alcoholic and unstable home. For these and other reasons, they may be reluctant – or simply unable – to be near the person who hurt them.

Money:
Adult children often fight over who controls the checkbook and how funds are spent. Some members of the family may harbor concerns about their prospective inheritance, causing them to question expenditures and even withhold care. There have certainly been many documented instances of “borrowing” from parental funds, too, when no such loans were granted, another natural springboard for conflict.

Denial:
Tensions commonly materialize when some members of the family are in denial about the gravity of a healthcare setback, or are simply less ready than others to acknowledge that the parent may not survive the current predicament. Arguments may erupt over the introduction of hospice/palliative care, the use of a Do Not Resuscitate Order, and treatment decisions.

Adult Disabled Children:
Mom or Dad’s health setback may impact an adult disabled child who relies on this parent for care and/or emotional support. A plan must be hastily put together to ensure the disabled family member’s needs are met, adding to the pressure of an already-difficult situation. Simmering beneath the surface may be concerns, too, that Mom or Dad won’t be able to care for this disabled family member anymore, and someone else will have to take responsibility.

Uneven Burdens:
In almost every family there is a perceived or real imbalance in the contributions made by adult children. The local daughter may do most of the work, simply because she is geographically close to the ailing parent. She may feel put upon, alone and unfairly expected to do everything. On the other hand, she may refuse offers of help because she has a need to control things and has had a major hand in creating the current workload imbalance.

The Patient’s Predicament
Whatever the history and dynamics of the family, there remains a patient in need of care. Often, the patient is aware of the tension and combativeness around them, and they may even feel a sense of responsibility for it. Long-held resentments will not be settled or solved at a time like this and, sadly, while family members are occupied by their own squabbles, they miss out on opportunities to spend quality time with the parent whose bedside they surround.

It is important for professional care providers to maintain a strong patient focus.   The care needs are here and now, and they can be addressed and resolved. It can be helpful to continually redirect family members back to this very basis proposition: We are here to help this particular family member, and their care needs must take precedence over ancillary family squabbles.

Care providers must also resist the temptation to take sides or to assume who is “bad” in a given situation. It is an easy, unconscious thing to identify with a member of a patient’s family who somehow mirrors the role we play in our own family. We inadvertently bring our own emotional baggage to the situation, and may inappropriately bond with one family member and assume their position is “right” or “good”. We can’t and won’t know the whole story, and it is not our place as professionals to judge. It is our primary job to deliver care to the patient.

How Can We Help?
Lifecare Innovations has experienced success in mitigating family disputes in difficult care scenarios, often through the skilled application of care management, clinical mediation and/or guardianship. Each of these approaches introduces an element of neutrality and offers warring family members an opportunity to take a break from one another and work through a calm, professional intermediary.

Lifecare Management
The benefits of a professional Lifecare Manager are invaluable in a complex medical situation, with or without family conflict. A qualified Lifecare Manager can assess the client, identify options and lead families through the crisis with knowledge, competence and the ability to get things done. As the healthcare system grows more complicated by the day, a care manager can navigate insurance problems, arrange for additional services and in every way make the family’s choices easier.

When conflict is an issue, Lifecare Managers can act as a neutral party and provide a much-needed buffer when family members find it difficult to talk to one another or even be in the same room. Family members often accept the recommendations of a professional more readily than they do the wishes of a sister, for example, and they may gladly assign the role of intermediary to a care manager to calm the conflict and strengthen the focus on care.

Clinical Mediation
Clinical Mediation is, essentially, assisted negotiation. There is a formal certification process to become a Mediator (Lifecare Innovations has two Certified Mediators). Families in conflict must agree to follow the guidelines laid out by the Mediator, all designed to achieve the goal of identifying reasonable and mutually acceptable options.

Mediation, unlike arbitration, is not binding. The Mediator assists the participants in framing objectives, generating and evaluating options and, ideally, developing a Memorandum of Understanding (a path forward on which all can agree). Mediation does not provide legal advice or therapy, and it does not guarantee outcomes. It is extremely helpful, however, in keeping families focused on objectives and narrowing down the options that have perhaps confused them and torn the family apart.

Guardianship
In instances where the patient’s decisional capacity is impaired, it is not unusual for family members to scramble for control of the destabilized family hierarchy – if Mom or Dad has been the de facto leader of the family for decades and now cannot make decisions, a power vacuum will form and some family members may rush to fill it. The patient is vulnerable and highly exploitable in a situation like this, and battles over money and leadership are likely to erupt.

If the ailing parent has not named a Power of Attorney, or if the named agent is suspected of exploitation or neglect and there is no successor agent, the matter could go to guardianship. It is not unusual for the court to hear arguments from each side of a split family as to which party should be named guardian. Sometimes, one side of the family will petition for a neutral third-party guardian to be named to calm the situation down and stop the cycle of endless fighting. Lifecare Guardianship has been named in such scenarios, assuring that an impartial professional will make responsible decisions that are neither punitive nor driven by emotion, and will communicate with all concerned.

 

Each of these solutions features a common characteristic: Neutrality. Siblings are often at peace with the role of a neutral professional simply because it means that a sister or brother they can’t trust is not in a position to deny them access to a parent. The sense that a solution is fair to all involved parties, and not weighted in one direction or another, tends to mollify distraught family members and lead to more effective decision-making and delivery of care.

The patient is safe, well-served, and finally, perhaps, able to achieve some level of peace as the professionals around them ensure their care needs are faithfully met.

©Lifecare Innovations, Inc.