Conflict Associated with Decisions to Limit Life-Sustaining Treatment in Intensive Care Units

Authors


Address correspondence and reprint requests to Dr. Tulsky, VA Medical Center (152), 508 Fulton St., Durham, NC 27705 (e-mail: jtulsky@duke.edu).

Abstract

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.

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