Conflict management teams in the intensive care unit: A concise definitive review

Interpersonal Conflict between Clinicians in the Delivery of Palliative and End-of-Life Care for Critically Ill Patients: A Secondary Qualitative Analysis

Background: Conflict between clinicians is prevalent within intensive care units (ICUs) and may hinder optimal delivery of care. However, little is known about the sources of interpersonal conflict and how it manifests within the context of palliative and end-of-life care delivery in ICUs. Objective: To characterize interpersonal conflict in the delivery of palliative care within ICUs. Design: Secondary thematic analysis using a deductive-inductive approach. We analyzed existing qualitative data that conducted semistructured interviews to examine factors associated with variable adoption of specialty palliative care in ICUs. Settings/Subjects: In the parent study, 36 participants were recruited from two urban academic medical centers in the United States, including ICU attendings (n = 17), ICU nurses (n = 11), ICU social workers (n = 1), and palliative care providers (n = 7). Measurements: Coders applied an existing framework of interpersonal conflict to guide initial coding and analysis, combined with a flexible inductive approach allowing new codes to emerge. Results: We characterized three properties of interpersonal conflict: disagreement, interference, and negative emotion. In the context of delivering palliative and end-of-life care for critically ill patients, "disagreement" centered around whether patients were appropriate for palliative care, which care plans should be prioritized, and how care should be delivered. "Interference" involved preventing palliative care consultation or goals-of-care discussions and hindering patient care. "Negative emotion" included occurrences of silencing or scolding, rudeness, anger, regret, ethical conflict, and grief. Conclusions: Our findings provide an in-depth understanding of interpersonal conflict within palliative and end-of-life care for critically ill patients. Further study is needed to understand how to prevent and resolve such conflicts.

Values and self-perception of behaviour among critical care nurses

BACKGROUND

Moral distress has various adverse effects on nurses working in critical care. Differences in personal values, and between values and self-perception of behaviour are factors that may cause moral distress.

RESEARCH AIMS

The aims of this study were (1) to identify ethical values and self-perception of behaviour of critical care nurses in Japan and (2) to determine the items with a large difference between value and behaviour and the items with a large difference in value from others.

RESEARCH DESIGN

A nationwide, cross-sectional study was conducted.

PARTICIPANTS AND RESEARCH CONTEXT

We developed a self-administered questionnaire with 28 items, which was completed by 1014 critical care nurses in Japan. The difference between value and self-perception of behaviour was calculated from the score of each value item minus the score of each self-perception of behaviour item. The size of the difference in value from the others was judged by the standard deviation of each item.

ETHICAL CONSIDERATIONS

The study was approved by the Ethics Committee of the Tokyo Medical and Dental University (approval nos. M2018-214, M2019-045).

RESULTS

The items with a large difference between value and behaviour sources were related to the working environment and decision-making support. The items with a large difference in value from others were related to hospital management and disclosure of information to patients.

DISCUSSION

Improving the working environment for nurses is important for reducing moral distress. Nurses are faced with a variety of choices, including advocating for patients and protecting the fair distribution of medical resources, and each nurse's priorities might diverge from those of other team members, which can lead to conflict within the team.

CONCLUSION

This study revealed items with particularly high risks of moral distress for nurses. The results provide foundational information that can guide the development of strategies to mitigate moral distress.

Conflict Management in the ICU

OBJECTIVES

To provide a concise review of data and literature pertaining to the etiologies of conflict in the ICU, as well as current approaches to conflict management.

DATA SOURCES

Detailed search strategy using PubMed and OVID Medline for English language articles describing conflict in the ICU as well as prevention and management strategies.

STUDY SELECTION

Descriptive and interventional studies addressing conflict, bioethics, clinical ethics consultation, palliative care medicine, conflict management, and conflict mediation in critical care.

DATA EXTRACTION

Relevant descriptions or studies were reviewed, and the following aspects of each manuscript were identified, abstracted, and analyzed: setting, study population, aims, methods, results, and relevant implications for critical care practice and training.

DATA SYNTHESIS

Conflict frequently erupts in the ICU between patients and families and care teams, as well as within and between care teams. Conflict engenders a host of untoward consequences for patients, families, clinicians, and facilities rendering abrogating conflict a key priority for all. Conflict etiologies are diverse but understood in terms of a framework of triggers. Identifying and de-escalating conflict before it become intractable is a preferred approach. Approaches to conflict management include utilizing clinical ethics consultation, and palliative care medicine clinicians. Conflict Management is a new technique that all ICU clinicians may use to identify and manage conflict. Entrenched conflict appears to benefit from Bioethics Mediation, an approach that uses a neutral, unaligned mediator to guide parties to a mutually acceptable resolution.

CONCLUSIONS

Conflict commonly occurs in the ICU around difficult and complex decision-making. Patients, families, clinicians, and institutions suffer undesirable consequences resulting from conflict, establishing conflict prevention and resolution as key priorities. A variety of approaches may successfully identify, manage, and prevent conflict including techniques that are utilizable by all team members in support of clinical excellence.

Reduction in Potentially Inappropriate Interventions in Trauma Patients following a Palliative Care Consultation

Background: Palliative care is expanding as part of treatment, but remains underutilized in trauma settings. Palliative care consultations (PCC) have shown to reduce nonbeneficial, potentially inappropriate interventions (PII), as decision for their use should always be made in the context of both the patient's prognosis and the patient's goals of care. Objective: To characterize trauma patients who received PCC and to analyze the effect of PCC and do-not-resuscitate (DNR) orders on PII in severely injured patients. Setting/Subjects: Retrospective cohort study of 864 patients admitted to two level 1 trauma centers: 432 patients who received PCC (PCC group) were compared with 432 propensity score match-controlled (MC group) patients who did not receive PCC. Measurements: PCC in a consultative palliative care model, PII (including tracheostomy and percutaneous endoscopic gastrostomy) rate and timing, DNR orders. Results: PCC rate in trauma patients was 4.3%, with a 5.3-day average time to PCC. PII were done in 9.0% of PCC and 6.0% of MC patients (p = 0.09). In the PCC group, 74.1% of PII were done before PCC, and 25.9% after. PCC compared with MC patients had significantly higher mechanical ventilation (60.4% vs. 18.1%, p < 0.001) and assisted feeding requirements (14.1% vs. 6.7%, p < 0.001). We observed a statistically significant reduction in PII after PCC (p = 0.002). Significantly less PCC than MC patients had PII following DNR (26.3% vs. 100.0%, p = 0.035). Conclusions: PCC reduced PII in severely injured trauma patients by factor of two. Since the majority of PII in PCC patients occurred before PCC, a more timely administration of PCC is recommended. To streamline goals of care, PCC should supplement or precede a DNR discussion.

Comfort care in trauma patients without severe head injury: In-hospital complications as a trigger for goals of care discussions

INTRODUCTION

Many injured patients or their families make the difficult decision to withdraw life-sustaining therapies (WLST) following severe injury. While this population has been studied in the setting of severe traumatic brain injury (TBI), little is known about patients who undergo WLST without TBI. We sought to describe patients who may benefit from early involvement of end-of-life resources.

METHODS

Trauma Quality Improvement Program (2013-2014) patients who underwent WLST were identified. WLST patients were compared to those who died with full supportive care (FSC). Patients were excluded for death within 24 h of admission, or head AIS > 3. Intergroup comparisons were by student's t tests or Wilcoxon rank sum tests; significance for p < 0.05.

RESULTS

We identified 3471 total injured patients without major TBI who died > 24 h after admission. Of these death after WLST occurred in 2301 (66% of total). This group had a mean age of 66.8 years; 35.7% were women, and 95.4% sustained blunt injury. WLST patients had a higher ISS (21.6 vs. 12.5, p = 0.001), more in-hospital complications (71.4% vs. 41.6%, p = < 0.0001), and a longer ICU length of stay (8.9 days vs. 7.5 days, p = <0.0001) compared to patients who died with FSC.

CONCLUSION

WLST occurs in two-thirds of injured patients without severe TBI who die in the hospital. In-hospital complications are more frequent in this patient group than those who die with FSC. Early palliative care consultation may improve patient and family satisfaction after acute injury when the timeframe to leverage such services is significantly condensed.