12.2.2 Attempting to Understand the Other Person’s Perspective

Shifting to a more constructive, nonjudging approach can be achieved by asking oneself the humanizing question, “Why is this otherwise reasonable and well-meaning person acting in this challenging and difficult way?” Three aspects are typically involved: (1) disagreements about the facts of the situation, (2) one’s emotional reactions to the situation, and (3) how one’s viewpoint limits the possible acceptable solutions [3].

Aspect 1: The Facts. Disagreements around the perceived facts of a situation often consume the greatest amount of time and energy during a difficult conversation. Often these disagreements are based on assumptions of the fundamental correctness of one’s perspective. In medical conflicts, clinicians often believe that they know the factual truth of the medical situation, and that, if the patient or family were reasonable, they would agree with them. This leads clinicians to neglect their patients’ viewpoints (which are as “true to them” as the clinicians’ medical facts). For example, the doctor may believe the patient is very unlikely to get better, while the family believes their dad has a very strong will and will beat the odds; both viewpoints are “true.”

There are a number of reasons why clinicians, patients, and families may not have the same set of facts [4]. It may simply be that the patient and family have not been told the medical information. Clinicians often speak in a manner that is strongly rooted in the medical culture, which may include scientific terms and jargon. Further, the terms clinicians use may be vague, especially when talking about prognostic issues. These may include using hedging phrases such as “cannot rule out” or trying to soften bad news by using phrases such as “may not do well” rather than “dying.” Additionally, various clinicians contributing to a patient’s care may have differing interpretations of the medical situation and give conflicting information. Finally, even when clinicians communicate clearly, they may still find that patients’ and families’ physical and emotional exhaustion may impede their ability to understand the clinician’s words.

Patients and family members who understand the medical details may nonetheless be in disagreement with health-care providers over the interpretation of this information. This may be caused by cultural and socioeconomic factors, as well as prior experiences with the medical system. For example, a family that has been told incorrectly in the past that a patient is not likely to survive an acute exacerbation of a chronic condition may refuse to accept the idea that he will not survive this episode. Families also receive information from other well-trusted sources, including friends and other family members, Internet sites, and television advertisements, and this external information may be in conflict with the information provided by clinicians. Finally, families may not believe the prognostic data is applicable to their loved one who they feel is stronger than most.

Clinicians often fail to hear and understand the patients’ nonbiomedical stories. Clinicians who spend time to learn these stories can better understand patients’ reasons for what may seem to be unrealistic decisions. Physicians may also underestimate the quality of life of chronically ill patients and therefore fail to accept descriptions of their level of functioning. Families who are given ample time to share their view of the facts of the situation report higher satisfaction with care and less conflict [5].

The key to resolving the “facts” aspect of conflict is to remember that these conversations are rarely about getting the facts right; the question at hand is about what each side believes is important. Each human being has a different background, a unique story, and, therefore, different perceptions of a situation informed by personal values. In order to find a solution, a clinician needs to be willing to learn more about the patient’s story. This is simply done by being curious, asking open-ended questions, and listening. After inquiring about the patient’s understanding of the medical information and filling in any relevant knowledge gaps, further questions to ask are, “What do you think is going to happen?” or “What do you hope that further chemotherapy will do?” or “I would like to understand; tell me more about your father’s illness.”

Aspect 2: The Emotions. Many conflicts have emotions lying at their roots. For example, a young woman whose spouse is dying in an intensive care unit may request medical interventions that are not likely to change her spouse’s condition. The woman’s sadness interferes with her ability to hear medical information, to consider what her husband might think about the situation, or to consider losing him. Trying to convince her that treatment is “futile” rather than addressing her intense grief is likely to result in heightened conflict. Attending to emotions and showing empathy helps patients feel supported and respected. This may then allow clinicians to build alliances with patients and move toward a mutual solution.

Clinicians, however, tend to avoid talking about emotions due to time constraints, personal discomfort with emotional crises, and a fear of releasing an uncontrollable flood of emotions. Physicians and other clinicians are also trained to maintain medical objectivity, and attending to emotions may feel insufficiently objective. A clinician’s medical training may not have sufficiently addressed methods to navigate emotional conversations.