The typology of conflicts in the ICU
By Élie Azoulay MD PhD, of the Medical Intensive Care Department, Saint-Louis University Hospital, Paris
Uncdertainty in prognoses causes symptoms of anxiety and depresiion in family members.
Intensive care units (ICU) are inherently stressful units. Indeed, patients’ severity and uncertainty in prognoses are responsible for symptoms of anxiety and depression in family members. Family grief, excessive workload and the complexity of every decision-making process lead to fatigue and burnout in nurses and doctors.
Conflicts could be defined as reported by Studdert et al. as ‘dispute, disagreement, or difference of opinion related to the management of a patient, involving more than one individual and requiring decisions or actions’. Even though conflicts might threaten the quality of care and have serious repercussions on daily ambiance, only a few studies report on the incidence, determinants and implications of ICU conflicts. Nurses, physicians, patients or family members can detect conflicts. They can be measured during an interview or by a questionnaire survey, and either during an ICU stay or after a patient’s discharge.
There are three main axes of conflicts: between caregivers and family members, which are characterized by distrust, inhibition of communication and family dissatisfaction. Intra-team conflicts with chaotic ambiance in the ICU that expose clinicians to burnout and to providing contradictory information to the family. Finally, intra-family conflicts that have been frequently reported at the end-of-life (EOL), a situation that creates inertia over making decisions.
Most of the information currently available on ICU conflicts comes from the EOL literature. However, several sources categories of conflicts have been identified. Namely, conflicts regarding poor communication, expected outcomes, coping problems, life sustaining therapies preferences (goals of therapy, level of care) and conflicts regarding symptoms control. Additionally, intra-team conflicts might be related to staff behaviour and lack of leadership and coordination, as well as during EOL care, when a family decision maker is not available.
Physicians and nurses perceive their teamwork climate differently and several studies have reported intra-team conflicts. Lack of communication has been highlighted. In addition, during EOL care, discrepancies have been reported, nurses being more pessimistic than doctors, more often correct in the judgment of dying patients, but proposed withdrawal in patients who survived. Nevertheless, conflicts are not the rule at the EOL.
According to the methodology used, the prevalence of conflicts varies. For instance, in a large US-study reporting 179 patients for whom a recommendation was made to withhold/withdraw life support, only 8 patients (4%) refused physicians’ recommendations to limit life support. Conversely, in a longitudinal study specifically aimed at identifying conflicts in 102 dying patients, Breen and colleagues performed 400 interviews with caregivers and found conflicts in about 80% of the cases. In 48% of cases these were between family and caregivers, in 48% of cases within the caregiver team, and in 24% of cases within the family. A less dramatic, but nonetheless harming picture, was reported by Abbott et al.
Given the paucity of ICU studies, clinical implication and relevance of conflicts are still unknown. Conflicts could be perceived as only devastating, or also useful, according to the solutions clinicians adopt to reduce conflict rates. For instance, in the specific context of EOL care, conflicts could result in a non-ethically acceptable decision-making process, in non-respect of a patient’s preferences and values, and in family dissatisfaction that will impart their decision-making capacity. Moreover, in a situation where the ICU becomes like a jungle, there is probably a risk of non-effectiveness of interventions aimed at improving end-of-life care.
Prevention of conflicts remains a major challenge. However, as a first step, a descriptive study on the typology of conflicts in a large number of ICUs will help identify clinical implications of conflicts, and also possible targets for interventions aimed at reducing ICU-conflicts. Intensive communication in the ICU seems to be a key component of prevention. Nurses reported the need to improve communication skills, for unit-level conferences and staff debriefing meetings. In addition, restoration of leadership and open discussions among all healthcare team members, during EOL decisions, is mandatory. Communication with family members will also help them cope with the distress of having a loved-one dying in the ICU, and empower them to share decisions. Recently, the effectiveness of intensive communication with family members was suggested, and demonstrated.
The Ethics Committee from the ESICM is currently designing the international Conflicus study, a one-day prevalence study on ICU-conflicts that will first define ICU-conflicts using definitions relevant for a large panel of investigators. Relevant situations of conflicts will be listed also. After this definition step, the prevalence of the identified situation, during a 24-hour study period, will be reported and targets for preventive strategies identified.
Contact: elie.azoulay@sls.ap-hop-paris.fr
01.03.2006
