As nurses and professional caregivers, we can all regale ourselves with accounts of family conflicts that seem to reach new heights as they unfold before us. We are amazed by what people say, at their behaviors in front of strangers, and to what levels they will go to hold fast to fiercely held beliefs and positions.

One way of resolving disputes - mediation - is popular in cases of divorce/dissolution, school peer mediation programs, and even business and federal mediation. Less known is Elder Mediation (EM) though it is growing in popularity in various states.

Elder Mediation involves parties sitting down with a neutral third party - a mediator - to hammer out differences involving any variety of issues: estate matters, end-of-life decisions, caregiver schedules to name a few.

Outpatient Options:

Depending on family needs and openness to levels of care, a number of alternatives are available.

• Geriatric Assessment: Gives families a "back door" approach when many seniors refuse to see a counselor. This comprehensive examination generally includes a spectrum of medical, psychological, neurological and social data-gathering and gives the family a "big picture" perspective as to the elder's condition.

"My game plan was for mom to see a counselor, because she wasn't sleeping, was losing weight, and cried on the phone every time I called her," said Nancy. "But every time I broached the topic her, she adamantly refused to see 'a young psychobabbler!'" Nancy learned about Geriatric Assessment offered at a local hospital, and was able to get help for her mother's depression and some good referrals for county services her mother needed for some early-onset dementia.

• Counseling: Allows either caregiver or elder some one-on-one time to deal with personal issues, work on family relationships, and at times, make decisions as a family as to ongoing needs of the senior. Because of the stigma many seniors perceive counseling to have, counseling is a hard sell to this generation that was taught to "offer it up" or "tough it out."

Amazingly, some seniors DO agree to counseling, usually when they have reached their limit, or find a free depression screening.

• Elder Mediation: Gives seniors input into making decisions that affect them and the family. Because the senior is involved in the process (rather than their adult children making decisions for them) there is an 85-90% success rate with compliance to the decisions. (Source: American Bar Association, Elden & Ziebarth, March, 1999).

"We tried so long to have family pow-wows, but dad always stormed out. He felt all we kids wanted was to get him to give up the car and move to a nursing home. What we really wanted was to come up with a game plan that took his needs and our busy work schedules into consideration," offered bakery owner, Jimmy G. "We found out about mediation from a friend of mine, and dad finally agreed to one session. He liked that he felt someone outside the family was hearing what he had to say. We got done in two hours what it took us months of yammering as a family to accomplish."

• Specialty Agencies: Most larger cities have an Office on Aging and/or Adult Protective Services. Some privately owned businesses, such as Cleveland-based Quality Care Options, help seniors and their families match senior needs with the best care providers.

Inpatient Options:

"As C.O.O. of Parma Community General Hospital, I (co-author, Pat Ruflin, RN) see so much more conflict now than ever before. The fast-pace of society, the high expectation that healthcare will keep people alive and well much longer, and the fact that most Americans wait until they are in crisis to begin to resolve it, all contribute to this increase."

On the inpatient side, these situations are all too familiar:

• Family members becoming hostile to the point of having staff or security intervene due to loud disagreements among siblings regarding their aging mother's care
• Adult children burned out by their parent's long history of depression and total dependence on the family. Now Dad is suicidal, and the family wants nothing more to do with him.
• Family disputes about end-of-life decisions despite the presence of a valid Living Will.

In all these examples, Elder Mediation offers the best possible outcome for the senior, the family, and the hospital staff. When arguments reach the point beyond which the case manager or patient liaison do not have time or training, mediators can step in.

Forging alliances with local mediation practices which specialize in Elder Mediation (i.e., mediators trained in family mediation and having experience/background in geriatric issues) is a viable option that our healthcare industry must address.

"Because mediators are intended to remain neutral, it makes sense for hospitals not to hire mediators internally. Case workers, social workers and other teams who work with families need to learn that they can refer for Elder Mediation, help resolve family disputes and come to some agreements that allow the family to return to the hospital with decisions that are made either prior to, during, or after the crisis," says local mediator, Dr. John Bertschler of Northcoast Conflict Solutions in Independence, OH. "Staffs are already stressed enough without trying to mediate these highly-charged family disputes."