Navigating the intensive care unit (ICU) can be daunting for patients and their families. Outcomes are uncertain and death is common in certain conditions.(1) Most patients lack the capacity to participate in medical decision making,(2) resulting in tremendous emotional burdens for surrogates. Potentially disparate moral perspectives between healthcare providers and surrogates can result in patient care disputes that damage relationships and impact decision making. Most differences can be mitigated through good communication, trust building and an understanding of patient and family values. However, a small percentage of differences cannot be easily negotiated. Conflict of this nature should be addressed proactively to minimize harm.
Substantial diversity of culture, religion and ethnicity exists in a pluralistic society, creating contrasting values and moral perspectives that directly impact how we choose to handle end-of-life circumstances. Individuals have different conceptions of what constitutes a meaningful quality of life and a “good death.” Surrogates are in a state of high stress and may process information emotionally rather than cognitively.(3) They may have difficulty understanding and using medical information critical to decision making. Additionally, physician time is consumed by technical tasks -- data processing, procedures, coordinating consultative care -- often limiting opportunities to engage families sufficiently. When they do engage, physicians may lack the skills necessary for navigating impasses and can experience moral distress when providing interventions they believe to be inappropriate. It is not surprising that efforts at good communication might fall short.
Communication breakdowns can result in power imbalances, loss of trust, entrenched positions, and stalemates. Consequences for families include complicated grief,(4) posttraumatic stress disorder,(5) anxiety, and depression.(6) For physicians, breakdowns can cause distress that manifests as avoidance, disengagement, cynicism, or burnout.(7) Physicians may call on ethics consultants when impasses arise in the ICU. However, on balance, ethics consults may be an inappropriate mechanism to resolve conflict. Good data on the composition and structure of ethics committees nationally is lacking, but anecdotal experience suggests they are typically comprised of hospital employees, many who volunteer and may lack dedicated ethics training. Inclusion of community members intended to represent the patient perspective is variable. Consequently, the committees often do not resemble the patient or surrogate. Additionally, the extent to which ethics consultants engage the patient or family when addressing concerns is unclear. Lastly, decisions by the ethics service may be rendered in a hierarchical manner with a vote either “for” or “against” one of the disputants (e.g., voting for the withholding of dialysis or cardiopulmonary resuscitation), resulting in a “win-lose” scenario. In reality, conflict often occurs in a state of what the Greeks termed moral aporia or uncertainty; most of these disagreements cannot be easily distilled down to “right” and “wrong.” In fact, most of the time differing ethical perspectives may each have validity. The concern then is that ethics consultants are given an undeserved moral authority to impose just one answer when neither party is wrong. Therefore, ethics consults may seem less than ideal.
A potential alternative is a more integrative negotiating strategy that has been employed for decades by mediators in business and law. In this form of bargaining, disputants are engaged simultaneously in an effort to create a “win-win” solution.(8) The goal is for disputants to walk away from conversations feeling their concerns have been recognized, creating an opportunity for catharsis intended to strengthen relationships and achieve an actionable resolution. Unfortunately, few clinicians are trained in principles of negotiation and availability of certified healthcare mediators is limited. One solution is to provide dedicated training in principles of mediation and integrative bargaining. However, this requires substantial time, resources and expertise. Another option is to engage colleagues already possessing enhanced communication skills. Specialists in hospice and palliative medicine may seem well suited to provide this service.
Palliative care is still a relatively new medical subspecialty currently undergoing tremendous growth in the United States. Historically, its roots are in the hospice movement, focused on the relief of pain and suffering at the end of life. However, hospice represents only a small fraction of the care that palliative care clinicians provide. At its core, palliative care providers focus on improving quality of life for patients and families living with chronic, critical or terminal disease. Clinicians trained in palliative medicine receive dedicated training in end-of-life care. They possess advanced skills in relieving physical and emotional distress and are adept at soliciting fears, hopes, wishes, and values. They also commonly have the ability to spend more time with patients and families, as doing so is part of their core mission. Consequently, they may be well positioned to act as intermediaries when conflict arises. This is not to suggest that ICU clinicians should abdicate responsibility for early and frequent engagement with patients and their families -- this remains an essential skill for clinicians to acquire and hone -- but palliative care consultants may be able to reestablish open lines of communication, foster trust and provide psychological and emotional support for both families and healthcare staff when relationships break down.
Ultimately, providing high quality communication for patients with critical illness is challenging. The ICU is an emotionally charged environment. Physicians and surrogates come from diverse backgrounds with differing end-of-life perspectives. Physicians may feel burdened by conflicting obligations to patients, surrogates and themselves. The result is an environment ripe for conflict, leading to difficult end-of-life experiences. It is incumbent on physicians to prioritize good communication in order to defuse conflict before relationships are damaged. When impasses arise, clinicians should seek assistance from individuals familiar with principles of integrative bargaining and who possess advanced communication skills. Training in healthcare mediation and negotiation may help clinicians navigate difficult conversations but requires substantial time and resources. In the absence of this training, palliative care specialists may be ideally suited to help achieve mutually agreeable resolutions, catharsis and a “good death” in the eyes of both the healthcare team and the family.
The contents of this work do not represent the views of the U.S. Department of Veterans Affairs or the U.S. Government.
1. Angus D, Barnato A, Linde-Zwirble W, et al. Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med. 2004;32:638-643.
2. Prendergast T, Luce J. Incidence of withholding and withdrawal of life support from the critically ill. Am J Respir Crit Care Med. 1997;155:15-20.
3. Tulsky J. Beyond advance directives: importance of communication skills at the end of life. JAMA. 2005;294:359-365.
4. Wright A, Zhang B, Ray A, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA. 2008;300:1665-1673.
5. Gries C, Engelberg R, Kross E, et al. Predictors of symptoms of posttraumatic stress and depression in family members after patient death in the ICU. Chest. 2010;137:280-287.
6. Pochard F, Azoulay E, Chevret S, et al.Symptoms of anxiety and depression in family members of intensive care unit patients: ethical hypothesis regarding decision-making capacity. Crit Care Med. 2001:29;1893-1897.
7. Azoulay E, Timsit J, Sprung C, et al. Prevalence and factors of intensive care unit conflicts: the Conflicus Study. Am J Respir Crit Care Med. 2009;180:853–860.
8. Fisher R, Ury W, Patton B. Getting to Yes: Negotiating Agreement Without Giving In. New York, NY: Penguin Publishing; 2011.