OBJECTIVE: To determine the incidence and nature of interpersonal conflicts that arise when patients in the intensive care unit are considered for limitation of life-sustaining treatment.
DESIGN: Qualitative analysis of prospectively gathered interviews.
SETTING: Six intensive care units at a university medical center.
PARTICIPANTS: Four hundred six physicians and nurses who were involved in the care of 102 patients for whom withdrawal or withholding of treatment was considered.
MEASUREMENTS: Semistructured interviews addressed disagreements during life-sustaining treatment decision making. Two raters coded transcripts of the audiotaped interviews.
MAIN RESULTS: At least 1 health care provider in 78% of the cases described a situation coded as conflict. Conflict occurred between the staff and family members in 48% of the cases, among staff members in 48%, and among family members in 24%. In 63% of the cases, conflict arose over the decision about life-sustaining treatment itself. In 45% of the cases, conflict occurred over other tasks such as communication and pain control. Social issues caused conflict in 19% of the cases.
CONCLUSIONS: Conflict is more prevalent in the setting of intensive care decision making than has previously been demonstrated. While conflict over the treatment decision itself is most common, conflict over other issues, including social issues, is also significant. By identifying conflict and by recognizing that the treatment decision may not be the only conflict present, or even the main one, clinicians may address conflict more constructively.
conflict (psychology) terminal care decision making life support care resuscitation orders
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Kohr R, Creces L, Gray V, Warnock L. Defusing family conflicts. Nursing 1998;28:54–7.PubMedGoogle Scholar
Jezewski MA. Do-not-resuscitate status: conflict and culture brokering in critical care units. Heart Lung. 1994;23:458–65.PubMedGoogle Scholar
Jezewski MA, Finnell DS. The meaning of DNR status: oncology nurses’ experiences with patients and families. Cancer Nurs. 1998;21:212–21.PubMedCrossRefGoogle Scholar
Jezewski MA, Scherer Y, Miller C, Battista E. Consenting to DNR: critical care nurses’ interactions with patients and family members. Am J Crit Care. 1993;2:302–9.PubMedGoogle Scholar
Shreves JG, Moss AH. Residents’ ethical disagreements with attending physicians: an unrecognized problem. Acad Med. 1996;71:1103–5.PubMedCrossRefGoogle Scholar
Winkenwerder W. Ethical dilemmas for house staff physicians. The care of critically ill and dying patients. JAMA. 1985;254:3454–7.PubMedCrossRefGoogle Scholar
Lo B, Saika G, Strull W, Thomas E, Showstack J. ‘Do not resuscitate’ decisions: a prospective study at three teaching hospitals. Arch Intern Med. 1984;145:1115–7.CrossRefGoogle Scholar
Smedira NG, Evans BH, Grais LS, et al. Withholding and withdrawal of life support from the critically ill. N Engl J Med. 1990;322:309–15.PubMedCrossRefGoogle Scholar
Prendergast TJ, Luce JM. Increasing incidence of withholding and withdrawal of life support from the critically ill. Am J Respir Crit Care Med. 1997;155:15–20.PubMedGoogle Scholar
Keenan SP, Busche KD, Chen LM, McCarthy L, Inman KJ, Sibbald WJ. A retrospective review of a large cohort of patients undergoing the process of withholding or withdrawal of life support. Crit Care Med. 1997;25:1324–31.PubMedCrossRefGoogle Scholar
Johnson D, Wilson M, Cavanaugh B, Bryden C, Gudmundson D, Moodley O. Measuring the ability to meet family needs in an intensive care unit. Crit Care Med. 1998;26:266–71.PubMedCrossRefGoogle Scholar
Cook DJ, Giacomini M, Johnson N, Willms D. Life support in the intensive care unit: a qualitative investigation of technological purposes. Canadian Critical Care Trials Group. CMAJ. 1999;161:1109–13.PubMedGoogle Scholar
Abernethy AP, Tulsky JA. Disagreements that arise when making decisions about withdrawing or withholding life-sustaining treatment. J Gen Intern Med. 1997;12(suppl 1):101.Google Scholar
Strauss AL, Corbin JM. Basics of Qualitative Research: Grounded Theory Procedures and Techniques. Newbury Park, Calif: Sage Publications; 1990.Google Scholar
Crabtree BF, Miller WL. Doing Qualitative Research. Newbury Park, Calif: Sage Publications; 1992.Google Scholar
Ellis DG, Fisher BA. Small Group Decision Making: Communication and the Group Process. 4th ed. New York: McGraw-Hill; 1994.Google Scholar
Rahim MA. Managing Conflict in Organizations. 2nd ed. Westport, Conn: Praeger; 1992.Google Scholar
Falk G. An empirical study measuring conflict in problem-solving groups which are assigned different decision rules. Hum Relations. 1982;35:1123–38.CrossRefGoogle Scholar
Dubler NN, Marcus LJ. Mediating Bioethical Disputes: A Practical Guide. New York: United Hospital Fund of New York; 1994.Google Scholar
Corley MC. Ethical dimensions of nurse-physician relations in critical care. Nurs Clin North Am. 1998;33:325–37.PubMedGoogle Scholar
Abbott KH, Sago JG, Breen CM, Abernethy AP, Tulsky JA. Families looking back: one year after discussion of withdrawal/withholding of life sustaining support. Crit Care Med. 2001;29:197–201.PubMedCrossRefGoogle Scholar
Levine C, Zuckerman C. Trouble with families: toward an ethic of accommodation. Ann Intern Med. 1999;130:148–52.PubMedGoogle Scholar
Katz J. The Silent World of Doctor and Patient. New York: The Free Press; 1984.Google Scholar
Wolf SM. Conflict between doctor and patient. Law Med Health Care. 1988;16:197–203.PubMedGoogle Scholar
Lo B, Quill T, Tulsky J. Discussing palliative care with patients. ACP-ASIM End-of-Life Care Consensus Panel. American College of Physicians-American Society of Internal Medicine. Ann Intern Med. 1999;130:744–9.PubMedGoogle Scholar
Goold SD, Williams B, Arnold RM. Conflicts regarding decisions to limit treatment: a differential diagnosis. JAMA. 2000;283:909–14.PubMedCrossRefGoogle Scholar
Forrow L, Arnold RM, Parker LS. Preventive ethics: expanding the horizons of clinical ethics. J Clin Ethics. 1993;4:287–94.PubMedGoogle Scholar
Dowdy MD, Robertson C, Bander JA. A study of proactive ethics consultation for critically and terminally ill patients with extended lengths of stay. Crit Care Med. 1998;26: 252–9.PubMedCrossRefGoogle Scholar