July 19, 2011

I am amazed at how many times, before I first meet a patient, I am warned by a member of my staff that the new patient is as nice as could be, but "watch out for the family." I guess I shouldn’t be surprised that we often encounter "difficult" families, as even seemingly perfect ones can behave or think differently when under stress or significant change – such as when a loved one needs placement into a long-term care facility.

But let’s not jump to conclusions. I have put my foot in my mouth many times by assuming I know what the family is thinking. And every time I do, you can bet that I have confused these people, or even shocked them.

This is why I try to start off all my family conversations by expressing how glad I am to meet them or see them again. I make sure I am introduced to all of the family members present and express disappointment if someone is not able to be at our meeting. Then I ask them to tell me what has been going on with their loved one.

This lets the family talk about what’s really on their mind – which is usually different from what is on my mind. For example, I was concerned about the medications a patient was taking and possible adverse side effects that I thought she was suffering from. But a daughter was most concerned that her mother was sleeping well through the night. I was able to use her concern to eliminate some medications that could contribute to poor sleep, such as furosemide taken at 8 p.m., which had been sending her to the bathroom in the middle of the night.

Today, most of us, as long-term care clinicians, are interacting daily with people of a multitude of cultures, social groups, ages, and economic positions. One of my favorite sayings is, "Once you’ve seen one elderly person, you’ve seen one elderly person." The same could be said for families.

Even if a family has a similar culture to your own, there can be differences in personality, personal experiences, and spirituality that influence how they hear your information and make decisions. A family could be labeled "difficult" because they don’t understand or interpret information presented by the clinician or staff. In this situation, it is best to have the family repeat back to you what they understand about what they have been told and what their expectations are.

Families Can Help

I did not know how helpful identifying family dysfunction could be to the family itself until I was taking care of "Mrs. B," who was very frail and had mild dementia.

Mrs. B had two daughters who were very involved in her care but could not agree on treatment decisions or goals of care. I have to admit that I judged one daughter to be much more realistic. Let’s call her "A-Plus." She was frustrated that her sister, "C-Minus," could not see that their mother was declining and needed 24-hour care and hospice.

I remember A-Plus stating that her mother would never disagree with C-Minus, and when the two of them were together, her mother acted like a different person. Mrs. B would even become childlike while C-Minus would talk "baby talk" to her mother.

I assured A-Plus that no family is perfect (which is true) and that there are many types of dysfunction that occur in families. I identified her mother and sister as having an "enmeshed" relationship, which I described as sometimes meaning high emotions, overprotectiveness, overinvolvement in care, unrealistic expectations, and insistence on overly aggressive care.

A-Plus’s eyes widened, and she said, "That’s it, that describes my sister and mother exactly!" I further explained that it was unlikely that the relationship could be changed and recommended the family seek professional counseling, which they actually did.

The facility’s staff and I tried to help the situation by providing frequent updates and looking for constructive ways for C-Minus to participate in the care of her mother. In future encounters, A-Plus always thanked me, and the relationship between the sisters and their mother did improve.

Theory and Execution

I like the structural family theory that was originally developed by Minuchin in 1974 and adapted for long-term care practice by Bluestein and Bach (J. Am. Med. Dir. Assoc. 2007;8:265-70). It says that family interactions are regulated by predictable patterns that are often passed from one generation to the next and are resistant to change.

This reminds me of the quote, "The apple doesn’t fall far from the tree." It also tells me that it is unlikely that long-term care clinicians, even with the help of an interdisciplinary team, can "fix" a dysfunctional family. However, being able to identify that there is a dysfunction and what kind of dysfunction it is can give us the tools to interact with "difficult" families in a civilized manner for the best interests of our patients.

In addition to enmeshment, Bluestein and Bach describe disengagement, hierarchies, triangulation, and coalition as other types of maladaptive family behaviors.

Disengagement occurs when family members are emotionally distant. They may not attend patient care conferences or return phone calls from staff and may be inclined to limit care prematurely. This may suggest that the family member could be suffering from depression or poor physical health or that the patient may have been an abusive parent or spouse. Gently inquiring into "why" a family member is distant may open up a flood of emotions that are hard to handle, but it can allow for a mental health referral so that the family member’s needs can be addressed.

Hierarchies occur when there is a family leader (often a "health expert") who sees suggestions from the clinician or staff as a challenge to his or her authority. In this situation, it is helpful for the clinician or a high-level staff member to form a partnership with the family leader and use objective data to support recommendations when there is a disagreement.

Triangulation occurs when a third party is used by two people to reduce anxiety or conflict. I see this fairly often when two siblings do not get along, but they are able to unite to express their dissatisfaction with a medical assistant, nurse, facility, or even the clinician regarding the care of their parent. While resolving triangulation would be difficult, recognizing the pattern may reduce staff frustration and allow for setting realistic boundaries.

Coalitions occur when family members take sides against other family members. One has to be careful not to take sides, too, even if you agree with one side. By taking sides, you may entangle yourself in the family conflict, which in turn can produce distrust. Providing families with objective information and encouraging them to talk out their differences is a wiser course.

Education about these patterns for staff is always beneficial. It can be as simple as a 1-2 minute discussion before a patient-care conference to remind ourselves why this particular family is difficult and how we can tailor our discussion so everyone (including the family) feels that they got the information they wanted and that the meeting was successful in identifying goals of care.

Or education can take place after a not-so-successful meeting to talk about what went wrong and try to identify what caused the interactions with the family to be difficult. The goal should always be to improve communication for future interactions with that family. CfA

"Board Room" is an occasional series of viewpoints from members of the Caring for the Ages editorial advisory board. Dr. Heffernan is assistant professor of medicine at the University of North Texas (Fort Worth) Health Science Center’s division of geriatrics. She is board certified in family medicine with a Certificate of Added Qualification in geriatrics and hospice and palliative medicine.

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