Family members often conflict with ICU staff
Duke study first to view problem systematically
A study done at Duke University has revealed that there is much more conflict between medical personnel and family members over withdrawing or withholding life-sustaining treatments for intensive care unit (ICU) patients than had previously been reported.1 Though such disagreements have been identified before, very few previous studies have examined the nature of the conflict that exists between family members of ICU patients and the medical personnel who provide and assess patient care.
"This was the first large study that tried to look at the issue in a systematic way," says James A. Tulsky, MD, associate professor of medicine at Duke University and lead author for the study.
Tulsky and his colleagues from the VA Medical Center and Duke University, both in Durham, NC, followed 102 consecutive cases of withdrawal of life support in five different intensive care units at Duke University Hospital. Researchers interviewed four health care providers for each of the cases, reporting on the amount of conflict perceived by two of the physicians and two of the nurses who were providing primary care to the patients. The physicians interviewed were the attending physician plus a fellow or a resident.
Conflict found in most ICU cases
In 78% of the cases studied, at least one health care provider described a situation they considered to be in conflict. "We found conflict occurred between staff and family members in 48% of cases, among staff members themselves in 48% of the cases, and among family members in 24% of the cases," Tulsky says. "Sometimes the conflict was both between family members and among staff."
Tulsky says the prevailing trend was that ICU staff wanted to pursue more aggressive therapy in more cases (76%) because they believed there was still a chance for the patient to recover. Family members favored aggressive measures in only 24% of cases studied.
Conflict is common in the ICU, Tulsky says, because communication between staff and family members is often inadequate or flawed, and the decision to withhold or withdraw support is by nature very emotional. It’s hard to imagine these situations without some disagreements and conflicts.
That may not be so bad, Tulsky says. Recognizing conflict makes it possible to deal constructively with the problem. "Not infrequently, conflict wasn’t even recognized," Tulsky says. "People aren’t talking to each other. They aren’t asking, How do you feel about this case?’"
As an example, Tulsky cites a number of situations in which two nurses said there was a lot of conflict but physicians said there was almost none. "Clearly, these nurses were very concerned over something that was going on, but they either never voiced their concerns to the physicians or the physicians never heard them," Tulsky says. "We should try to elicit people’s concerns to find out if conflict actually exists."
Minimize conflict with communication
Tulsky says the most important issue is conflict prevention. "Once it’s there, it’s a different story," he says. ICU personnel can probably minimize conflict through more open communication between staff and patients by anticipating what peoples’ concerns might be and by discussing goals of care and prognosis. "We may not be able to make it go away, but at least some of the worst cases can be prevented," he says.
It’s essential that communication about prognosis and goals of care begin very early on. Tulsky says keeping the patient’s family informed about the patient’s response to therapy and treatment options keeps people from being "blindsided" by requests to limit treatment.
The Duke study found that in 63% of cases, the subject of conflict was a disagreement between family and staff over the decision to withdraw or withhold treatment. Physicians and nurses have seen these kinds of cases many times before, so they know how bad the prognosis really is, Tulsky says. This means they begin to move along in their own adjustment to the impending grief of losing that patient.
However, it’s the first time the family has been in a situation like this. "They get pieces of information about lab values or whatever, but they don’t realize how serious it is, so at the point that the team is thinking about withdrawing support, the family hasn’t gotten there yet," Tulsky says. "If you’re not honoring the difficulty they’re having over the sickness of their loved one, it’ll be hard to talk about the nuts and bolts of actually making a decision."
Clarify conflicts by identifying issues
Finally, Tulsky says, ICU personnel should recognize that conflict is not always about what it seems to be about. He notes that it’s important to figure out whether the conflict is actually rooted in a difference of opinion about life-sustaining treatment or whether it stems from miscommunication, personality conflict, or unaddressed emotional or social issues.
In about 20% of the cases studied, conflicts developed around personal behavior or blame, Tulsky says. In several of these cases, ICU staff members felt frustrated because families who rarely visited the patient made decisions about life-sustaining treatments.
"Is the issue that there’s a difference in values, in which the family is saying, Given our values, we believe that the life we see in our parent is a quality of life worth living and we would therefore continue’?" he asks. "Or is the conflict because people are angry with each other or there’s a grieving process going on that needs to be addressed?"
Reference
1. Breen CM, Abernethy AP, Abbott KH, Tulsky JA. Conflict associated with decisions to limit life-sustaining treatment in intensive care units. J Gen Intern Med 2001; 16: 283-289.
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