Family Conflict

Background

Palliative care can have a trajectory of days, weeks or months and during this time care needs such as symptom management, emotional, physical and spiritual are mainly provided by informal caregivers, family and friends. Providing end of life care to a loved one is associated with significant burden and strain and can alter the relationship dynamics between the carer and care recipient as well as the wider family. The research indicates that when there is conflict within a family unit, poor patient clinical outcomes are observed including lower recovery rates from acute episodes, reduced adherence to medications and reduced quality of life.

This summary discusses the evidence for managing family conflict in the context of palliative care.

Evidence Summary

Healthcare guidelines for the management of palliative care in a number of countries note the importance of supporting the carers, although frequently the information is aimed at carers of recipients with cancer only. [1] Despite the detrimental outcomes of distress, burden and conflict to both the carer and care recipient within a family care arrangement, being able to identify risk of burden and conflict is problematic. A review by Staccini et al (2015) looked at tools that might help assess family functioning and found the FAD tool (Family Assessment Device) of clinical merit in both the assessment and management of family conflict; although its usefulness with older adult palliative care recipients and their carers has not been evaluated. [2] In an earlier (2008) systematic review outside of the scope of the search for this summary, authors concluded that conflict is often caused by a number of sources including historical issues of tension, different coping styles, the division of labour and presence of acute or mental illness within the family. [5]

In anticipation of burden, distress and grief a number of interventions have been proposed and delivered to carers and care recipients, predominantly in a face-to-face format. In a systematic review by Candy et al (2011), authors identified 11 randomised controlled trials (RCTs) evaluating the usefulness of interventions to assist carers with either improved wellbeing and/or grief management, but none looked at practical support strategies. Only one RCT within the review makes mention of managing conflict, and notes that those families already in high levels of distress were more likely to reject help and where the intervention was accepted, findings were an increase in  reported conflict rather than improvement. [1]  This finding is mirrored in a low-quality review by Shields et al (2012) who as part of another review of family health interventions found three studies where grief interventions were more likely to increase distress in ‘hostile’ families. [3] Finally, a systematic review of 32 papers looking at psychological distress in families in palliative care (Carolan et al, 2015) found that communication styles differed subtly between genders, with females more likely to be expressive and ‘hostile’ and males more likely to ‘withdraw’ with a failure to communicate. Overall the studies propose that active communication can both negatively or positively impact distress depending on the preferred process of communicating between the family unit [4] and thus raises significant confounders in how best to support families in conflict. In summary, there is a paucity of research on managing conflict within a family in a palliative care setting, [1] and what research has been drawn on in this summary is predominantly of low quality [2,3,6] and low applicability to this population group and setting. [4]

Quality Statement

In summary, more robust and quality research and practice guidelines are needed addressing family conflict, for a range of diagnosis in an older adult cohort and in the palliative care setting.