Splitting
2019; Wiley; Volume: 55; Issue: 10 Linguagem: Inglês
10.1111/jpc.14532
ISSN1440-1754
Autores Tópico(s)Family Support in Illness
ResumoRecent high-profile cases of conflict between parents and health-care professionals regarding end-of-life care in the UK (Charlie Gard, Alfie Evans) and regarding the treatment of brain tumour in the UK (Ashya King) and Australia (Oshin Kiszko) have highlighted conflicts between parents and health-care staff. Early predictors of intractable conflict include family attempts to micro-manage care, avoidance and communication breakdown.1-3 A UK Royal College of Paediatrics and Child Health consensus paper gave sensible advice on conflict management strategies, including assigning a Lead Clinician, involving palliative care teams early and seeking ethical and legal advice if mediation fails.2 Recently, some of the families in our hospital have ‘sacked’ their lead clinician and demanded a replacement of their choice from within the same team. This has thrown our clinician colleagues into a quandary. Family-centred care aims to give parents agency to make joint decisions with clinicians, but when do such demands become unreasonable? Clinicians have always been urged to accede to requests for a second opinion, even when there is virtually no doubt the second opinion will concur with the first. Paediatrics is specialised such that the second opinion may necessarily be from within the same institution, although ideally, it should be a truly unbiased opinion from an outside clinician. However, the aim of a second opinion is to offer an unbiased lens and to support or educate the lead clinician, not to dismiss them. When families single out one clinician as purportedly being the only member of the team who understands the parents, it could be seen as an example of ‘splitting’ (Fig. 1). In classical psychoanalytical terms, splitting was seen as an unconscious defence mechanism for complex entities with aspects that are both acceptable and unacceptable. People may unconsciously separate or ‘split’ objects into the ‘good’, acceptable side of a person or thing and the ‘bad’, unacceptable or painful side. Sigmund Freud used the term splitting to mean a way of resolving ambivalence by splitting contradictory feelings so that one person is only loved and another one only hated, much like the good mother and the wicked stepmother from fairy tales. It suggests concrete black-and-white thinking, with no nuanced shades of grey. The psychoanalyst Melanie Klein wrote: ‘the earliest experiences of the infant are split between wholly good ones with ‘good’ objects and wholly bad experiences with ‘bad’ objects’.4 In her object relations theory, she described how children struggle to overcome the tendency to split objects, allowing them to integrate the two primary drives of love and hate into constructive social interaction.4 The term splitting is sometimes used in the modern vernacular to denote deliberate or conscious splitting, as in the ancient military tactic of ‘divide and rule’. Teenagers are often adept at splitting parents. If one parent says no, ask the other parent without telling him or her that his or her partner said no. One parent becomes the ‘bad’ punitive parent; the other is the ‘good’ lenient parent. The teenager plays on this split, which causes or increases inter-parental conflict. One way to deal with it is for the parents to agree in advance what the consequences (not the punishment) will be if the teenager strays, for example, breaks an agreed curfew. Then, the parents can support each other in applying the consequences. When the teenager calls them names, the parents can shrug and say: ‘You knew what the consequences would be, so it was your choice.’ This approach also supports a young person's developing autonomy. When the parent of a child patient tries to sack the lead clinician, we may be well advised to treat it like an adolescent who tries to sack a parent. Parents may feel like being sacked, but clinicians have to collaboratively set clear boundaries and consequences. If we allow a parent to sack the lead clinician and choose their favoured one, the parent is appealing to the chosen clinician's desire to be liked or even their intrinsic narcissism. It is seductive to be told by a parent that ‘you are the only one who truly understands them’. But to ensure their demands are met, the parent will prefer the clinician they can most easily manipulate. Sacking the lead clinician generally does not serve the child's needs better and may impair the child's trust in the treatment team, an important part of the treatment. It damages the functionality of the treatment team, both for this child and for other children in the team's care. It is very damaging for both the lead clinician sacked and the new person. It may turn into a Child Protection issue if parents pitch unshakeable belief against medical expertise. The resources consumed often amount to a disproportionate amount of personal and professional time in which the clinician finds him- or herself simultaneously under attack from parents, even fellow consultants, and with administration often drawn into the conflict. These circumstances can cause even solid clinicians to develop mental health symptoms and can have destructive impacts on personal relationships. Dealing effectively with the ‘I'm sacking you’ declaration requires a cohesive team deciding in advance not to allow this to happen. The parent may legitimately request an external expert opinion, but the team should agree that no other consultant from the team will step up to become the new lead clinician. Both families and clinicians should continue to negotiate shared decision-making for the best interests of the sick child. This commonality should be the mutual focus to enhance the child's welfare.5 The parent may have the option to seek care at another hospital or to pay for a private opinion, but the clinicians should be resolute and stand united to resist dismissal at all costs. Splitting is damaging. We acknowledge valuable advice from Dr Stephen Isaacs, Dr Ken Nunn and Professor Dominic Fitzgerald.
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