Collusions Between Patients and Clinicians in End-of-Life Care: Why Clarity Matters

Abstract

Collusion, an unconscious dynamic between patients and clinicians, may provoke strong emotions, unreflected behaviors, and a negative impact on care. Collusions, prevalent in the health care setting, are triggered by situations which signify an unresolved psychological issue relevant for both, patient and clinician. After an introductory definition of collusion, two archetypal situations of collusion-based on material from a regular supervision of a palliative care specialist by a liaison psychiatrist-and means of working through collusion are presented. The theoretical framework of collusion is then described and the conceptual shortcomings of the palliative care literature in this respect discussed, justifying the call for more clarity. Finally, cultural aspects and societal injunctions on the dying, contributing to the development of collusion in end-of-life care, are discussed.

The Collusion Classification Grid: A Supervision and Research Tool

“…To the Editor Burnout is a real concern for palliative care practitioners (PCPs) regularly caring for seriously ill patients and families. 1 In our previous study, we found the prevalence of burnout to be 33% among PCPs in Singapore. 2 A recent study showed the prevalence among U.S. palliative care clinicians 3 to be as high as 62%.…”

“…It provokes intense emotions and/or unreflected behaviors. 1,2 For example, a patient with great difficulties coping with separation, due to prior life events (early losses), faces death and, consequently, separation from loved ones. He requests assisted suicide, arguing that he is tired of life; he is not aware that the request is motivated by his desire to hasten separation, a process he greatly fears (to ''get it over with'').…”

“…A colluding clinician might explain his attitudes and rationalize his stance, but he does not access the underlying dynamics which tie him so strongly to his patient. Indeed, in collusion, a threatening or otherwise uncomfortable confrontation 1,4,5 with the issue at stake is suppressed by both, the patient and clinician.…”

“…Supervision is an effective means to identify and work through collusion. 1,4,5,8 Intense emotions reported in supervision, such as anger or anxiety, or feelings of malaise or guilt after reacting inadequately to a patient, provide clues that collusion might be at work. Based on regular supervision of a palliative care physician (K. N) 1 by the first author (F. S.), enriched by his longstanding experience in clinical supervision, 8,9 and an ongoing discussion among the coauthors, we tried to identify the different components of collusion.…”

Moving toward the next generation of communication training in oncology: The relevance of findings from qualitative research

“…This objective also requires methods that enable or enhance introspection, since clinician's own emotions, perceptions and attitudes potentially erect barriers between the clinician and the patient. Outer barriers, such as those discussed under section 3.5 (study of Dencker et al, 2017), utilised for defensive purposes by clinicians, can also be addressed and modified by means of methods facilitating introspection, such as individual and group supervisions or Balint-inspired groups (Stiefel, Nakamura, Terui, & Ishitani, 2017). Such a clinician-centred approach, which has recently been endorsed by the third European consensus meeting on communication in cancer care, has the concurrent advantages of (a) being generic, in the sense that it is not a situation-specific approach, multiplying training methods related to different topics; (b) stimulating a reflective process, which benefits the clinician and the patient; (c) directly addressing participants' individual resources and possibilities; and (d) limiting the amount of predefined communication behaviours to be acquired.…”