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

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

Studdert DM; Mello MM; Burns JP; Puopolo AL; Galper BZ; Truog RD; Brennan T

Intensive Care Medicine

2003

Female; Humans; Male; Adult; Prospective Studies; Aged; Middle Aged; Family Relations; Professional-Family Relations; Boston; Communication Barriers; Length of Stay; Dissent and Disputes; Interprofessional Relations; Time Factors; Reproducibility of Results; Case-Control Studies; 80 and over; decision making; ICU Decision Making; Intensive Care Units/statistics & numerical data; Intensive Care/statistics & numerical data

OBJECTIVE: 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. PATIENTS: 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). CONCLUSIONS: 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.

2003

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