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In every workplace, including hospitals, conflicts can include parties who are not present. We call them shadow participants, but in reality they may be much more substantial than mere shadows. When patients are involved, either as principals or as subjects of disputes, these shadow participants may be more powerful than the patients. The shadow participants become surrogate voices for the ones they love or support. They are the families: the spouses, partners, children, parents, and relatives whose lives are affected by whatever the patients are experiencing. When patients are not able to speak for themselves, and often even when they are, the surrogate or shadow parties can be invited to participate in a Dispute Resolution process. Sometimes they have legal standing, such as a Power of Attorney for Healthcare, and sometimes they don't, but they are related to patients and believe they speak for them. Whether or not families are active participants, they are affected by the patients' treatment; therefore, taking the interests of family members into account is critical to a successful Exchange process.


Cases involving decision making by family members about patient care are never easy. They involve high emotions. Yet the opportunity to speak in a structured process monitored by the facilitators allows the parties in the situation to express those emotions and be heard in a respectful way and then to think more rationally during the decision-making process.

In the private meeting (Stage One), the facilitator may need to help the family member consider his or her choice of words, tone, and fundamental interests. The facilitator helps one family member decide if the purpose of his or her action is to prove that the other family member is wrong or is to do what is best for their loved one. The facilitator can help one family member find language that won't cause the other family member to tune out.

Without the structure of The Exchange's Stage Three—attention to an icebreaker, the impact, and the issues—it would be very difficult to move beyond blame and self-righteous declarations. In times of emotional stress, human brains (and the human beings whose skulls they inhabit) are flooded with emotion-producing chemicals that make it difficult to think logically and participate in more dispassionate discussion. Having a facilitator to keep the process moving forward allows an empathic exchange of feelings and a constructive conversation about alternatives.

The facilitator may assume the role of coach in situations among family members or between patients and their families, just as he or she coaches the provider in a provider-patient case. The facilitator is often dealing with vulnerable individuals, consumed with their own perspective of the situation.

However, people cannot just "set aside" their emotions. During the joint meeting (Stage Three) the facilitator ...

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