Intensive Care Medicine

, Volume 29, Issue 9, pp 1489–1497 | Cite as

Conflict in the care of patients with prolonged stay in the ICU: types, sources, and predictors

  • David M. Studdert
  • Michelle M. Mello
  • Jeffrey P. Burns
  • Ann Louise Puopolo
  • Benjamin Z. Galper
  • Robert D. Truog
  • Troyen A. Brennan



To determine types, sources, and predictors of conflicts among patients with prolonged stay in the ICU.

Design and setting

We prospectively identified conflicts by interviewing treating physicians and nurses at two stages during the patients' stays. We then classified conflicts by type and source and used a case-control design to identify predictors of team-family conflicts.

Design and setting

Seven medical and surgical ICUs at four teaching hospitals in Boston, USA.


All patients admitted to the participating ICUs over an 11-month period whose stay exceeded the 85th percentile length of stay for their respective unit (n=656).

Measurements and results

Clinicians identified 248 conflicts involving 209 patients; hence, nearly one-third of patients had conflict associated with their care: 142 conflicts (57%) were team-family disputes, 76 (31%) were intrateam disputes, and 30 (12%) occurred among family members. Disagreements over life-sustaining treatment led to 63 team-family conflicts (44%). Other leading sources were poor communication (44%), the unavailability of family decision makers (15%), and the surrogates' (perceived) inability to make decisions (16%). Nurses detected all types of conflict more frequently than physicians, especially intrateam conflicts. The presence of a spouse reduced the probability of team-family conflict generally (odds ratio 0.64) and team-family disputes over life-sustaining treatment specifically (odds ratio 0.49).


Conflict is common in the care of patients with prolonged stays in the ICU. However, efforts to improve the quality of care for critically ill patients that focus on team-family disagreements over life-sustaining treatment miss significant discord in a variety of other areas.


Physician-patient relations Conflict (psychology) Intensive care Withholding treatment Communication barriers Ethics, medical 


  1. 1.
    Fischer JE, Calame A, Dettling AC, Zeier H, Fanconi S (2000) Experience and endocrine stress responses in neonatal and pediatric critical care nurses and physicians. Crit Care Med 28:3281–3288Google Scholar
  2. 2.
    Fins JJ, Solomon MZ (1996) Communication in intensive care settings: the challenge of futility disputes. Crit Care Med 29:N10–N15Google Scholar
  3. 3.
    Jamerson PA, Scheibmeir M, Bott MJ, Crighton F, Hinton RH, Cobb AK (1996) The experiences of families with a relative in the intensive care unit. Heart Lung 25:467–474PubMedGoogle Scholar
  4. 4.
    Prendergast TJ (1997) Resolving conflicts surrounding end-of-life care. New Horiz 5:62–71PubMedGoogle Scholar
  5. 5.
    Cook DJ (1997) Health professional decision-making in the ICU: a review of the evidence New Horiz 5:15–19Google Scholar
  6. 6.
    Bucknall T, Thomas S (1997) Nurses' reflections on problems associated with decision-making in critical care settings. J Adv Nurs 25:229–237CrossRefPubMedGoogle Scholar
  7. 7.
    Asch DA (1996) The role of critical care nurses in euthanasia and assisted suicide. N Engl J Med 334:1374–1379CrossRefPubMedGoogle Scholar
  8. 8.
    Viney C (1996) A phenomenological study of ethical decision-making experiences among senior intensive care nurses and doctors concerning withdrawal of treatment. Nurs Crit Care 1:182–187PubMedGoogle Scholar
  9. 9.
    Burns JP, Mello MM, Studdert DM, et al (2003) Results of a controlled clinical trial on care improvement for the critically ill. Crit Care Med (in press)Google Scholar
  10. 10.
    Kristjanson L (1993) Validity and reliability testing of the FAMCARE scale: measuring family satisfaction with advanced cancer care. Soc Sci Med 36:693–701CrossRefPubMedGoogle Scholar
  11. 11.
    Breen CM, Abernethy AP, Abbott KH, Tulsky JA (2001) Conflict associated with decisions to limit life-sustaining treatment in intensive care units. J Gen Intern Med 16:283–289CrossRefPubMedGoogle Scholar
  12. 12.
    Abbott KH, Sago JG, Breen CM, Abernethy AP, Tulsky JA (2001) Families looking back: one year after discussion of withdrawal or withholding of life-sustaining support. Crit Care Med 29:197–201PubMedGoogle Scholar
  13. 13.
    Marcus LJ (1995) Renegotiating health care: resolving conflict to build collaboration. Jossey-Bass, San FranciscoGoogle Scholar
  14. 14.
    Corbin J, Strauss A (1990) Basics of qualitative research: grounded theory, procedures and techniques. Sage, Thousand OaksGoogle Scholar
  15. 15.
    Le Gall JR, Lemeshow S, Saulnier F (1993) A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA 270:2957–2963 (erratum appears in 271:1321)Google Scholar
  16. 16.
    Cullen DJ, Civetta JM, Briggs BA, Ferrara LC (1974) Therapeutic intervention scoring system: a method for quantitative comparison of patient care. Crit Care Med 2:57–60PubMedGoogle Scholar
  17. 17.
    Keene AR, Cullen DJ (1983) Therapeutic Intervention Scoring System: update 1983. Crit Care Med 11–1–3Google Scholar
  18. 18.
    SUPPORT Principal Investigators (1995) A controlled trial to improve care for seriously ill hospitalized patients. JAMA 224:1591–1598Google Scholar
  19. 19.
    Smedira NG, Evans BH, Grais LS, Cohen NH, Lo B, Cooke M, Schecter WP, Fink C, Epstein-Jaffe E, May C, Luce JM (1990) Withholding and withdrawal of life support from the critically ill. N Engl J Med 322:309–315Google Scholar
  20. 20.
    Prendergast TJ, Luce JM (1997) Increasing incidence of withholding and withdrawal of life support from the critically ill. Am J Respir Crit Care Med 155:15–20PubMedGoogle Scholar
  21. 21.
    Asch DA, Hansen-Flaschen J, Lanken PN (1995) Decisions to limit or continue life-sustaining treatment by critical care physicians in the United States: conflicts between physicians' practices and patients' wishes. Am J Respir Crit Care Med 151:288–292PubMedGoogle Scholar
  22. 22.
    Kleinpell RM, Powers MJ (1992) Needs of family members of intensive care unit patients. Appl Nurs Res 5:2–8PubMedGoogle Scholar
  23. 23.
    Hupcey JE (1998) Establishing the nurse-family relationship in the intensive care unit. West J Nurs Res 20:180–194PubMedGoogle Scholar
  24. 24.
    Cooper-Patrick L, Gallo JJ, Gonzales JJ, Vu HT, Powe NR, Nelson C, Ford DE (1999) Race, gender, and partnership in the patient-physician relationship. JAMA 282:583–589CrossRefPubMedGoogle Scholar
  25. 25.
    Saha S, Komaromy M, Koepsell TD, Bindman AB (1999) Patient-physician racial concordance and the perceived quality and use of health care. Arch Intern Med 159:997–1004CrossRefPubMedGoogle Scholar
  26. 26.
    Smedley BD, Stith AY, Nelson AR, eds (2002) Unequal treatment: confronting racial and ethnic disparities in health care. National Academy Press, WashingtonGoogle Scholar
  27. 27.
    Teno J, Lynn J, Wenger N, Phillips RS, Murphy DP, Connors AF Jr, Desbiens N, Fulkerson W, Bellamy P, Knaus WA (1997) Advance directives for seriously ill hospitalized patients: effectiveness with the patient self-determination act and the SUPPORT intervention. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. J Am Geriatr Soc 45:500–507PubMedGoogle Scholar
  28. 28.
    Danis M, Southerland LI, Garrett JM, Smith JL, Hielema F, Pickard CG, Egner DM, Patrick DL (1991) A prospective study of advance directives for life-sustaining care. N Engl J Med 324:882–888PubMedGoogle Scholar
  29. 29.
    Morrison RS, Olson E, Mertz KR, Meier DE (1995) The inaccessibility of advance directives on transfer from ambulatory to acute care settings. JAMA 274:478–482CrossRefPubMedGoogle Scholar
  30. 30.
    Bowman KW (2000) Communication, negotiation, and mediation: dealing with conflict in end-of-life decisions. J Palliat Care 16:S17–S23PubMedGoogle Scholar
  31. 31.
    Hoffman DE (1994) Mediating life and death decisions. Ariz Law Rev 36:821–877PubMedGoogle Scholar
  32. 32.
    Schneiderman LJ, Gilmer T, Teetzel HD (2000) Impact of ethics consultations in the intensive care setting: a randomized, controlled trial. Crit Care Med 28:3920–3924Google Scholar
  33. 33.
    Dowdy MD, Robertson C, Bander JA (1998) A study of proactive ethics consultation for critically and terminally ill patients with extended lengths of stay. Crit Care Med 26:252–259PubMedGoogle Scholar
  34. 34.
    Larson DG, Tobin DR (2000) End-of-life conversations: evolving practice and theory. JAMA 284:1573–1578CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2003

Authors and Affiliations

  • David M. Studdert
    • 1
  • Michelle M. Mello
    • 1
  • Jeffrey P. Burns
    • 2
  • Ann Louise Puopolo
    • 3
  • Benjamin Z. Galper
    • 1
  • Robert D. Truog
    • 2
  • Troyen A. Brennan
    • 1
    • 3
  1. 1.Department of Health Policy and ManagementHarvard School of Public HealthBostonUSA
  2. 2.MICU Office/Farley 517Children's HospitalBostonUSA
  3. 3.Division of General Internal MedicineBrigham and Women's HospitalBostonUSA

Personalised recommendations