Some ethics consults in the ICU center around conflict between clinicians caring for a critically ill patient. To learn more, researchers interviewed 17 ICU attendings, 11 ICU nurses, and seven palliative care providers.1
“Data for this analysis came from a qualitative data set where we were aiming to understand different factors associated with adoption of specialty palliative care services in the ICU,” explains May Hua, MD, one of the study’s authors and assistant professor of anesthesiology at Columbia University Medical Center.
In reviewing the data, Hua and colleagues noted some striking examples of conflict occurring between clinicians in the context of palliative and end-of-life care delivery.
“While palliative and end-of-life care are known to be a source of conflict in the ICU setting, we found that there was actually very little data to understand why conflict occurs and how it is experienced by clinicians,” Hua reports.
Clinicians described conflicts centering around a disagreement on whether palliative care was appropriate for a patient, or how care plans should be prioritized, or how care should be delivered. There was a clinician preventing palliative care involvement or goals-of-care discussions. Negative emotions were common — a clinician silencing, scolding, or speaking rudely to another clinician, or a clinician feeling anger, regret, or grief.
“These study data are important for ethicists to be aware of, as they are often called into situations with conflict and may be tasked with mediating between conflicted parties,” Hua says.
Hua and colleagues noted clinicians who experienced interpersonal conflict spoke about the experience quite vividly, despite the incident occurring some time ago. “Understanding the emotions that go along with conflicted situations, as well as common differences in clinician perspectives surrounding palliative and end-of-life care, may help ethicists serve as a mediator and provide the appropriate ethical frame for issues as they arise,” Hua suggests.
ICUs rely on multiple clinicians and staff members to support a patient through a life-threatening illness, notes Joanna Hart, MD, MSHP, a pulmonary and critical care physician at the University of Pennsylvania. Thus, disagreements on the best approach to an individual patient’s care are common.
“This can be a wonderful aspect of ICU care, as it promotes thoughtful, thorough discussions. But if there are opposing opinions about the next best step, this can lead to conflict within the team,” Hart says.
There are some common scenarios Hart sees in the ICU:
• Clinicians disagree on the patient’s chances of survival. In some cases, the patient had already received multiple types of chemotherapy, but the cancer continued to progress, and the patient developed respiratory failure. While in the ICU, the intensivist assessed the patient and concluded that even with maximal life-sustaining therapies, the patient was highly unlikely to survive the critical illness.
In contrast, the oncologist, who knew the patient for years, believes the patient has a chance with ICU care to recover well and long enough to receive further chemotherapy. “This is a conflict of prognosis that may lead the intensivist to experience moral distress,” Hart notes.
The intensivist is providing invasive, burdensome critical care to a patient while believing it is potentially inappropriate, as it would not benefit the patient. In cases like those, ethicists sometimes find there are intractable differences of opinion between ICU clinicians.
In those cases, says Hart, “the ethics team can help navigate what the options would be, such as transferring the patient to other clinicians to avoid needing to provide care that is causing a clinician moral distress.”
• Nurses feel excluded from end-of-life care decisions. In some cases, the intensivist held a family meeting with a critically ill patient’s family and several consulting clinicians. According to the family, the patient still would value a health state with complete dependency and requiring invasive life support. Based on the family’s input, clinicians decide to pursue continued critical care.
Later, the intensivist explains the decision to the ICU nurse, who was not invited to the meeting. The nurse is upset at missing the discussion. “The nurse experiences moral distress, and feels that this is potentially inappropriate care and should not have been offered as an option,” Hart says.
• ICU clinicians disagree on interpretation of policies and rules. Visitation restrictions during the pandemic put ICU clinicians in the difficult position of advocating for individual patients while navigating new policies.
“The policies were new and rapidly changing, and ICU teams were under a great deal of stress,” Hart says. Some hospital policies permitted two family members to be present for the death of a critically ill patient.
However, some patients had a spouse and two adult children. One ICU clinician might advocate for allowing an exception so all three could be present. Another might be frustrated that clinicians made an exception for one family.
“Who makes the final decision and what to communicate to the family might be a point of conflict for these two individuals,” Hart says.
Including the necessary clinicians in key decisions can prevent some conflicts. If conflict already exists, ethics consults can facilitate communication to resolve it. “Ethicists are often seen as a neutral party,” Hart says. “Their review of a situation can help provide space to reflect on how the conflict arose.”
REFERENCE
- Tong W, Murali KP, Fonseca LD, et al. Interpersonal conflict between clinicians in the delivery of palliative and end-of-life care for critically ill patients: A secondary qualitative analysis. J Palliat Med 2022; Apr 1. doi: 10.1089/jpm.2021.0631. [Online ahead of print].
Ethicists often are seen as a neutral party. Their review of a situation can help provide space to reflect on how the conflict arose.
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