The fact that I'm going first means it can only get better as the day goes on. And so we'll go ahead and get started. Any questions about how things are gonna work for the next 90 minutes? Awesome. So I have no conflicts of interest or other disclosures. And I realize as I'm about to go through this case, I realized that I didn't put in a learning objectives slide, so I apologize. But what we're gonna do over the next 20 minutes is I'm gonna go through some principles of conflict management, where it came from, what it looks like. We're gonna go through how you identify conflict and then how you can resolve conflict. We're gonna do it using this case as an example. So a 71-year-old man is hospitalized in the ICU. I'm sorry, I apologize. How many physicians in the room? Okay, surgeons? Nice. Anesthesia? Home crit care? What am I missing? Peds critical care? Nice, that's the big group. Okay, I just wanna get a lay of the land of what we have. Neurocritical care? Okay, did I miss anything? All right, how about pharmacists? How about nurse practitioners? How about PAs? Awesome. This is great. This is what I love about SCCM is how multidisciplinary and collaborative it is. And so we're all going to bring unique perspectives to the cases as we work through them. So this is a 71-year-old man who's hospitalized in the ICU for three weeks with COVID-19 pneumonia and ARDS. Sorry for any flashbacks or PTSD. He has persistent hypoxemic respiratory failure, currently vented on 100% oxygen, sedated on neuromuscular blocking agents, proned on inhaled prostacyclin with oxygen sets that are still consistently in the 80s. The ECMO team says he's not a candidate due to age and duration of illness. The ICU team recommends limiting life-sustaining therapies in the context of his unremitting COVID pneumonia and ARDS. The family becomes angry and accusatory, claiming the team is trying to kill the patient, demanding that the team does everything possible to keep him alive, threatening lawsuit if they do not. Team members express frustration that he's suffering and that we're torturing him. Several of the nurses press you to be more forceful with the family and place limitations on life-sustaining therapies. You're distressed over his unrelenting illness, your inability to rescue him, feeling pushed by team members to make him DNAR and comfort care, suffering you might be causing him, and limitations on visiting hours for family of a dying patient, and fatigue from ongoing COVID care. None of you guys have probably had a case like this, so hopefully I fleshed it out for you in a way that you—it sounds plausible. It is not advancing. Thank you. So just a definition of conflict, I think we all know what conflict looks like and feels like, but it's an opposing action of incompatibles, so it's an antagonistic state. And conflict, by its nature, is sort of a win-lose environment. It's where you have two individuals who are disputing something, two or more individuals, they believe very strongly they're right, they're entrenched in their own perspectives, the other individual feels that their opponent is incorrect, and really, for the most part, conflict ends either in a stalemate, where no one wins, or in a win-lose situation, where somebody walks away the victor and the other person really doesn't feel like they were heard or got their message across. And ideally, we want to be in a win-win scenario, so we're going to talk a little bit about what win-win looks like. Yeah, so this is not working, but I can just say next slide. Awesome. You're the man. Thank you. So the moral position is that we are in this state of moral aporia, so a moral position is a stance that an individual or group of individuals will take based on this inherent underlying conception of right versus wrong. I'm right, you're wrong, that's my position, end of story. And the real challenge is that we often are in this state of ambiguity, especially when you're dealing with moral issues, where there may be multiple principles in conflict, you may both have reasonable moral perspective on why you're right and why the other person is not. There may be more than one justifiable moral outcome, and so you're in this kind of state of what the Greeks called perplexity or aporia. And so I think what's important to recognize first is that very rarely is it ever actually ethical, unethical, or right and wrong, and I think that we can all think of examples in our practice where there was a dispute or an argument or a disagreement, and it really wasn't about either party being wrong, it was just difference in perspective and difference in viewpoint. There are certain circumstances certainly where someone's behaving frankly unprofessionally or unethically, and we have one case that we'll go over that's a lot like that, but there are moments when there's clearly a right and a wrong because someone is just behaving so inappropriately, they're just frankly acting unethically. But more often than not, we're in situations where there really is a fair consideration of either perspective, and we need to have that acknowledgement. So if you look back at the law and business literature, which is really where conflict management originated from, there's three main sources of conflict. There's substantive, process, and relational. And substantive is, I've sort of reframed it in terms of medical practice, what we do in healthcare. Substantive would be unethical behavior, there's something there, or maybe even an adverse event or a medical error where something has actually happened. Process is where it could be something medical legal, so you have an advanced directive or a power of attorney that says, I want X, and then the family comes in and says, I know what they wrote, but they changed their mind, or we feel differently, we want to give them a chance. Or it could be something around hospital policy or hierarchy, for example, being told you can't come in and see your loved one because there are limitations on visiting hours, and that process issue can be really challenging to work through. And then the last is relational, where it's really about values-based judgments or even communication breakdown. And I'll pause here and say that the back half of my talk is going to be really providing the group here with language that you can use when you are in these moments of conflict to help begin to reduce the conflict. And I'm sure everyone in this room are really good communicators. You don't get into healthcare and not be able to communicate effectively. But I'm going to challenge you and say that if you look at the communication literature and you think about these ideas of relational communication, how we relate to people as people, and you look at even things like palliative care literature versus ICU literature and how we communicate, we're very process-oriented in the ICU, and they're much more relational in palliative care. And actually, when you go through palliative care training, as I did, you learn a lot of communication techniques that can be incredibly valuable. And so while I don't want to sort of suggest that you don't know how to communicate, I would also say that you don't know how to use a ventilator until you figure out how to turn the knobs. And you don't understand pharmacokinetics or how to hang a drip and run an infusion until you've learned how to do it. And I think that language can be taught as well. So that's part of what I'll do at the end. So you get all of these conflict triggers, all the things that are going on in the environment of care, patients' experiences, the way we communicate, family dynamics, culture, power dynamics between the family and the healthcare team where we're sort of in our home base in the hospital in the ICU, our own concerns about mistrust, our inability to prognosticate effectively, our own compassion fatigue. You put these all together, and it creates this perfect environment for conflict to brew in the ICU. And you get conflict that results in communication breakdown because we become entrenched. And as we are entrenched, we step back and we say, I'm not going to talk about this anymore. I'm going to either compete with you or I'm going to really avoid it and not even go into the room and talk to the family, which we've all probably at some point have done. You get entrenched. You get really morally injured and distressed. I feel like I want to do X. I want to treat this way, and I can't because I'm being prevented. There's something in the hierarchy of the hospital or the mechanics of the hospital or in the family dynamics that doesn't allow me to execute the care that I think is the right thing to do for this patient. And it results in disengagement. And then you have this sort of constant cycle. And with that cycle, you get profound injury to patient and family. You get distrust. You get complicated bereavement. You get PTSD, anxiety, depression from family members. The profession takes a hit. We all remember at the beginning of COVID when everybody's going out at 7 p.m. and banging pots and pans, health care heroes, and you fast forward like a year, and people are yelling at you in the hospital because you're trying to kill their loved one, right? So something changes in the way we trust each other. And then it's damaging to self because that results in us burning out. It results in us becoming morally injured and losing some of our compassion, our empathy, our desire to put one foot in front of the other. And we leave the profession. And we've all had colleagues who've said, I've had enough, I'm going into industry, or I'm changing hospitals, or I'm actually just not going to do this anymore. So that's the lay of the land, then, of how conflict develops. And so now I'd like to talk a little bit about mediation, introduce mediation to you. So that's me in the middle there, a balding guy with glasses, and I've got the dog and the squirrel. And I say, first, can we all agree that it's a big backyard? There's plenty of room for everyone. That's what a mediator does. They're in the middle. They're in neutral. And they work together. And it comes from business and law, where you actually have time to sit down at a table and arbitrate and hear from each individual and caucus with each individual and work with each individual and try to come to a shared conclusion. And that's great. But who has time to do that in health care, right? We don't stop and say, time out, the patient's dying, they're on a ventilator, but we're not going to let them die. We're going to sit down for three hours, and we're going to mediate, and we're going to figure it out. We're all going to come to a nice kumbaya, and we're going to be happy, and we're going to walk away. That would be the ideal. But the pressures of what we do make it nearly impossible. So what if, instead, we could teach some of these mediation techniques to you so that you could then employ them, although you're not a neutral, you're biased because you're part of the health care team. You're not coming in as a complete neutral. You can still use these techniques. So the number one role of a mediator is to bring down the emotional temperature in the room. So everybody's at a five, and you're heated, and they're yelling or screaming or pointing fingers or angry or folded arms, not talking, not sharing. Maybe they're very quiet. Maybe they don't come to the family meetings. Maybe they don't come into the hospital at all, right? Maybe it's not patient and family versus us. Maybe it's us versus us, right? Maybe it's that conflict that we have at the bedside between nurse and physician or between consulting physician and primary team. The consulting team is coming in and not even letting you know they're there, and they're going and talking to the family and saying one thing, and you say something else, and the family's wondering why we're not talking to each other, right? These are the things that happen naturally in health care that we should try to avoid. So how do you bring down the emotional temperature in the room so that everybody's thinking a little bit more cognitively and not so affectively or emotionally? The second thing that a mediator would do is they listen first. They try to tease out the nature of the conflict, facilitate dialogue not with me as the mediator, but between the two disputants with each other. They problem solve and educate, maybe clarify misconceptions when they hear something that someone else is misinterpreting. So it's a little bit of a therapy session. And then they resolve dispute so that you can come to this win-win, what's been described in the business literature as a win-win resolution where you may not get exactly what you want, but you walk away from the table feeling like you've been heard and that you have a shared decision that you can live with. So what are the rules of conflict management if you're doing it yourself, if you're trying to negotiate with someone on the other side of that proverbial table that is arguing with you? So anger is a reactive emotion, and the key is finding its source. So if someone's angry, if someone's demonstrating moral emotions, resentment, indignation, frustration, you need to figure out where that's coming from. It only takes seconds to escalate a brewing conflict. So it's really important to recognize you have to be very careful with your words. Calling someone out for bad behavior will make things worse. I will give you a great example. My daughter is 14. And when I tell her that she's watching too much TikTok, magically, it doesn't make her more calm. It actually causes a great deal of conflict. And so I'm quite good at this in the hospital and maybe not so good at home, but hopefully she or I will grow out of it. Naming the concern demonstrates alliance and avoids creating an adversary. So being able to say, I recognize your concern, I hear your concern, I want to validate your concern as being reasonable, normalizing things, and then beginning to work through it. And then a sincere apology or expression of consolation can go a long way. So it doesn't have to be an expression of being wrong, of fault, right? I'm sorry I erred, but rather it can be, I'm really sorry that you're feeling this way or that we've come to this sort of tension between us. How can we work through it, right? And so I'll give you some language on how we can do that. What are the goals of conflict management? Well, there's three main goals. One is developing situational awareness of when conflict is brewing. Sometimes it can be quite obvious. Family member yells. Other times it can be a little bit more insidious, right? And we don't totally pick up on it. So having that spidey sense can be really helpful. Separating positions from interest, and I'll define the difference between positions and interest in a moment. And then using relational communication skills to de-escalate conflict. And it's really using a lot of the language that we learn in our palliative care training on how to communicate and meet people's needs that I think is most helpful. So first, let's develop situational awareness. Well, it's understanding that conflict is a unique syndrome, and it usually involves moral emotions. So the ones I named before, anger, resentment, indignation, frustration, and they are distinct from other complex discussions. This is not the family member where you share with the patient and the family that they're dying and you offer an expression of consolation, I wish things were different, but this is where we are. And they're very sad, they're tearful, they allow you to put your arm on their shoulder or to give them a hug if they're okay with that. This is a different situation because it's immediately adversarial. And you, me, we are the person that they are ascribing that anger to. So something I did in their mind generated this. So you have to be able to figure out what are the triggers that resulted in the conflict that is brewing, and then have the capacity to diagnose it as it's happening and then extinguish it. Next slide. And I will say that big fires, really big fires, like the houses on fire is probably not the time for you to be using these skills. This is for like really small fires where you can sort of be like the person with the fire extinguisher. If it's a big fire, you got to call the fire department, right? That's where you call palliative care, that's where you call an ethics counsel, that's where you call an ombudsman, that's where you think about things like transferring the patient to a different service. Like those are really big fires where you're just not going to be able to put it out through just conversation. So let's talk about the positions versus interests. So positions is what I want. So in this case, it's I want you to save my family member from COVID. I don't believe that they're dying, and you can do better, and you need to save my family member. And the team is like, I want this patient to be comfort care because they are dying and we're torturing them. That's very binary. You're not going to have a lot of room for negotiation if that's talking about what I want. But if you think about the interest instead, which is why I want it, what is underlying the family's request, or in this case, demand for you to do more? What is it that's driving them to try to push for that? And then also being able to look inward and have what Ta-Nehisi Coates calls muscular empathy, right? So why is it that I believe what I am saying, and why am I in this position, and why is it that I want that? And is it possible that maybe I need to be thinking from their perspective better to understand why there's a disconnect? So being able to own some of that and have that humility is really important. And so when you focus in on why I want it, you think about a colleague of mine has sort of described this as a tree and roots. And so what I want is really like what you see above the ground. It's the trunk. It's the branches. It's the leaves. And why I want it is the roots. You don't see those until you start digging. So that's what you have to do is start digging. And once you step back and you figure that out, you start thinking more about values, perspectives, goals, what is driving an individual to say, I want you to do X. It really allows you to see that alternative position and that why instead of the what. And you begin to find common ground where you can actually compromise and achieve that win-win. So we've all found ourselves on a lot of different sort of positions on this TKI instrument. This has been around since the 1970s. And you can think of it really as varying levels of cooperativeness and assertiveness. And so we've all had situations where we're very accommodating, right? So the family member says, I want you to do dialysis. And you're like, oh, man, I've been fighting so much with this family. You know what? You want dialysis? Cool. Go ahead. Dialysis. Right? I'm accommodating. That doesn't really get us to where we need to go. You can also be really avoidant. I'm not going in the room today. They yelled at me yesterday. So you know what? I'm going to kind of walk by. I'm going to examine them from the door. Right? But I'm not actually going in the room today. And then you could also be competing. No. We're not going to do dialysis. It's not medically indicated. It's not appropriate. And it's a non-starter. And then you could be collaborating or compromising. And we really want to be in that collaborative or even compromising space where we're trying to we're defending our ground, right? So whoever it is that's disputant, we're not going to sort of just give up and say, OK, whatever you want. But we're also finding ways to figure out exactly what they're thinking and how we can sort of meet their needs. Next slide. So how do you do this? Well, you utilize relational communication skills. You listen first. You need to be inquisitive and ask questions, show curiosity. You need to show empathy. Acknowledge different perspectives, that my perspective is not the only right one. Write any perceived wrongs. And I put it in quotations because we're not always wrong. But if the person who is expressing those moral emotions believes that you are wrong and is angry at something that you have done, great example, patients in the ICU develop acubitus ulcers, pressure ulcers, skin breakdown. Our nurses do an amazing job of turning patients constantly. We do a great job of trying to manage fluid balance. We try to avoid them getting pressure injury. But the truth is, sometimes if a patient's really sick, the skin is an organ and it breaks down, right? And a family member sees that and they get really upset, like you're not providing good care, right? How could you do this? This is Penn Medicine, right? You're supposed to be such an amazing place where you work. How could you let my family member do this? Well, it's not going to do any good to say, I'm sorry, but you know, things happen, right? This happens. It's part of being sick. Like that's not going to in any way get them to align with you. But rather you say, I'm so sorry that this happened. I imagine for you, it must look like they're really not doing very well and maybe we could have done better. Can we talk about that, right? And then you can sort of begin to align with them. And then you find ways to compromise ultimately, because you're not going to always get exactly what you want. So here's some examples of what each of these skills or descriptions of what each of these skills look like. So active listening is reframing and restatements that you can use to demonstrate what you've heard. It's a good way to align with people if you're able to sort of like, you know, what we call like wigging. So what I get or what I hear you say, right? What I heard you say was this. I'm showing that I'm listening actively. Being inquisitive, asking lots of questions of people to try to tease out their concerns better, understand the positions and the interests. Empathizing, so using the nurse mnemonic, which I'll show you in a moment, but acknowledging, validating and respecting their struggle. Acknowledging the different perspectives that there may be more than one reasonable outcome. Next slide. Naming the emotions. So literally saying, I can tell you're really angry, right? Or it seems like you're frustrated, right? Can be really helpful because it acknowledges and ultimately will validate their lived experience, what they're feeling. Abandoning the more high ground. Going in, like you got to check your ego at the door. Going in and saying like, I'm right, they're wrong, and I'm not going to ever say that I'm not right is not helpful, right? Again, righting any wrongs, finding ways to apologize, and then compromising to find that win-win. If you're going to walk away from this talk with one thing that I think would be most helpful, it's the nurse mnemonic. How many people have heard of the nurse mnemonic? Okay, good. So, I mean, not good that a lot of people haven't heard of it, but good that it's something you're not familiar with because this, I think, can revolutionize the communication that you do with your patients, families, and colleagues. I use this all the time. So the nurse mnemonic came around in the 1980s. It came in the oncology literature for how to communicate and deliver bad news and respond to intense emotions. It's been validated and revalidated time and time again over the last 40 years, almost 50 years. Naming, so identifying the emotion being expressed. Understanding is demonstrating appreciation for that emotion. Embracing is expressing praise for how they're handling the emotion. Supporting is supporting the patient through those emotions. Then exploring is understanding that emotional state at any time and continuing to explore where it's coming from. It is a fantastic mnemonic. Any time that you're going to deliver bad news, be prepared for emotions. And when those motions occur, being able to lean into those emotions is really important. Next slide. So just some language that you could use. So oftentimes when I'm naming it, I'll say, you know, many people in your situation would feel, and name that emotion, frustrated. Is that how you're feeling? Or I imagine if I were in your situation, I might be frustrated. Is that what you're feeling? Understanding. You're not alone in feeling this way. Many people would feel this way or it's very common to feel this way, so that normalizes it for them that when they're feeling this anger, this frustration, this sense of sadness, whatever it is, that it's actually not just them that has that feeling. Respecting it. This must be really hard for you. You've done such an amazing job taking care of mom. Or you've been such a strong advocate. Thank you for being here. Supporting. You're not going through this alone. We're going to be here with you every step of the way. We're here for you too. I like to say that when patients are sick, families suffer too, and so we're here to support you too. You're a part of our responsibility. And then exploring. I imagine it's been really difficult. How are you doing? Is there anything you've been feeling that you'd like to share? Finding that space for them to share what is sort of behind that strong request or adamant stance that they're taking really helps break down barriers. So in summary, I think conflict management training should be a core competency of what we do for all of us. I think it can help us provide a moral intuition about when we think something is amiss. It can help us improve our active listening skills. It can also help us find the patient and family or even our colleagues' truth, what they believe, to explore options that might be available for us to find that common ground, respect each other's values and preferences, handle really challenging, morally complex and charged emotions, compromise, provide a high-quality communication atmosphere that whoever it is you're speaking with feels like they're being heard, which is all any of us as human beings ever really want, and then searching for that win-win. So that's a little bit of a primer on conflict management. Thanks so much. You want to have a sign?

conflict management

medical case presentation

COVID-19 pneumonia

ARDS

relational communication skills

conflict triggers