Conflicts associated with decisions about withholding or withdrawing life-sustaining treatment have received a great deal of publicity. While some cases such as those involving Karen Ann Quinlan and Nancy Cruzan end up in court and the media, most conflicts related to end-of-life decision making do not involve the legal system. Nonetheless, health care providers are frequently confronted with them during every day practice. Even without legal action, these conflicts can have serious consequences. They may negatively affect the quality of decision making and patient care, as well as the satisfaction of both family members and health care providers.1
Despite the importance of conflict during end-of-life decision making, little is known about its prevalence, causes, and effects. The existing literature focuses primarily on the problem of nurse-physician conflict2,3 and nurse-family conflict,4 and emphasizes coping mechanisms for nurses rather than improving patient care.5–7 Two small studies have looked at the conflicts between resident physicians and attending physicians,8,9 and disagreement between physicians and patients or family members has been identified in several series of hospitalized patients.10–13 Others have provided details about the human element of high technology in the setting of intensive care.14,15 However, conflict was not the main focus of these studies, and information about the occurrence of conflict was assessed through limited means such as chart review or questionnaires filled out by a single physician.
To address these shortcomings in the literature, we studied intensive care unit patients for whom withholding or withdrawing treatment was considered. Interviewing primary nurses and physicians from each case, we analyzed the incidence, nature, and participants of conflicts. Describing these situations is essential in identifying whether and how to address them.
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Health care providers perceived conflict in 78% of the cases of decision making for critically ill patients. Although no other study has been specifically designed to assess the prevalence of conflict, this figure is significantly higher than noted in previous studies. For example, Smedira11 found that fewer than 10% of families disagreed initially with a recommendation to limit support. In a study of medicine inpatients based on physician report, Lo10 found that 4% of patients and family members disagreed with a recommendation for a DNR order and 3% of families had disagreement among themselves. Prendergast and Luce12 examined the time it took to reach agreement as a surrogate marker for both staff-family and staff-staff conflict. They found that, in 16% of cases, the primary care team and the critical care team were delayed in agreeing to present the family with a recommendation to limit life-sustaining treatment. Once a recommendation was made, 39% of patients or surrogates failed to agree immediately to limit treatment. Whether these delays were caused by conflict is not known. In our study, definite disagreement between staff and family over the treatment decision was present in 33% of the cases (this included both families who disagreed with a recommendation to limit treatment and families who wanted to limit treatment but met with staff disagreement).
There are several possible reasons why we found a much higher rate of conflict than previous studies. First, we used interviews rather than surrogate markers or chart reviews to identify conflict. Second, we interviewed 4 providers per case. This increased the likelihood of talking with someone who perceived conflict. Third, we spoke to both nurses and physicians. Nurses bring a perspective that may be more closely aligned with the patient or family.1–4,23 Fourth, we did not rely on individual interpretations of what qualified as conflict but instead applied an external definition. This definition did not limit conflict to those situations in which action was delayed because of disagreement or in which a decision was made in spite of ongoing objections by 1 or more parties. Furthermore, the conflict did not have to be openly discussed by the involved parties.
Conflicts over the actual life-sustaining treatment decision have received the most attention in the literature and were the most common cause of conflicts in this study (63% of cases). However, we also found that other tasks caused conflict in a significant number of cases (45%). These other tasks included communication to family members, communication among staff, communication among family members, pain control, and the process of decision making. One common problem occurred when staff members, despite agreeing about the treatment decision, disagreed about how to discuss the situation with family members. Jezewski5 also found that health care providers had disagreements about the timing of or approach to obtaining family consent. Poor communication created problems when all staff members did not understand the proposed care plan. Other research by Jezewski6 also supports the finding that conflict can derive from disagreement about whether a DNR order means “comfort care only.”
Intrafamily conflict was identified in one quarter of the cases; staff-family or staff-staff conflict each occurred in nearly half of the cases. This difference may reflect a true difference in the incidence of conflict. Another explanation is that we spoke only with staff members. Staff members may be more aware of conflicts involving themselves and less aware of conflicts occurring within families. In a companion study of family perceptions of conflict, family members were aware of more family conflicts and fewer staff conflicts.24
This study has several limitations. We did not have codes for the severity of conflict. Indeed, they ranged from disagreements lasting a few hours or a day to conflicts that continued to the patient's death and beyond. For staff-family conflicts, it was also difficult to determine whether the family merely needed a little time to prepare for the patient's death before agreeing to withdraw treatment. Finally, this study was limited to patients in intensive care units. Less conflict may exist during end-of-life decision making in other settings, such as the regular ward, clinic, and home.
Although we report a high frequency of conflict during decisions to withhold or withdraw life-sustaining treatment, we do not presume that conflict is necessarily bad. Just as there is constructive criticism, there can be constructive conflict. For example, when staff members disagree on the appropriate level of treatment, each side may have legitimate concerns that need to be addressed. In addition, the patient's condition may be changing or uncertain, making a decision difficult. Disagreement over the decision between the family and staff may reflect deep-seated differences in values. Levine and Zuckerman25 warn against the tendency to label involved, vocal families as “trouble.” A period of dissent may be necessary for both sides to appreciate the other's perspective and to find accommodation. Conflict between patients and physicians has also been proposed as an essential step in breaking paternalistic behavior patterns.26,27 Lack of appropriate conflict may contribute to the “illusion of patient choice” described by Orentlicher.28
These data provide clinicians with several take-home lessons to improve decision making for critically ill patients. First, given the high levels of conflict and the variability in perception of conflict among different staff members, clinicians should strive to recognize conflict so that it can be dealt with constructively. Second, many of the disagreements we identified were not caused directly by different opinions about limiting treatment. Physicians facing a conflict-filled situation should try to determine whether the conflict is actually rooted in a difference of opinion about life-sustaining treatment, or whether it is caused by miscommunication, personality conflict, or unaddressed emotional or social issues.29–31 Efforts can then be directed at resolving the particular issue at hand. Third, health care providers should try to identify potentially conflict-ridden situations to prevent discord. Keeping families informed about the patient's response to therapy and what treatment options remain throughout a patient's illness may reduce the likelihood that families will be “blind-sided” by a request to limit treatment. “Preventive ethics” may help avert unproductive conflict and needlessly difficult decisions.32,33
One of our cases illustrates these points. Early on, the staff recognized that there was staff-family conflict over personality and communication issues, and the initial therapy decisions. They used aggressive, consistent communication efforts to address the family's concerns. When the time came to make a decision about treatment withdrawal, the family trusted the staff, and there was no disagreement.
These findings suggest that much could be done to improve the culture of care and decision making in critical care units, and multiple resources are available to help. Dubler and Marcus22 provide a mediation approach to resolving bioethical disputes. Levine and Zuckerman25 emphasize the goals of partnership and accommodation with families. Goold et al.31 focus on understanding the reasons behind the conflict and emphasize communication skills. For staff-staff conflicts, Edwards2 outlines approaches that include calling care conferences, involving ethics committees, and using specific facts from the case at hand as well as published references, when appropriate.
The recognition that disagreements during life support decisions are frequent and varied is an important first step toward reducing the conflicts experienced by many doctors, nurses, and family members. Further research into the best ways to resolve conflicts is needed.