Conflicts over difficult, complex decision-making is common in ICUs. Such disagreements negatively affect patients, families, clinicians, and institutions, according to the authors of a recent literature review.1
“Since conflict is so prevalent in the critical care areas, understanding how to best prevent conflict from occurring is imperative,” says Joshua B. Kayser, MD, MPH, the study’s lead author and director of the medical ICU at Cpl. Michael J. Crescenz VA Medical Center in Philadelphia.
Of course, not all conflict can be prevented. “Methods of managing it and ultimately resolving conflict are key skills that can be taught to everyone in healthcare,” says Lewis J. Kaplan, MD, the study’s co-author and the VA’s section chief of surgical critical care.
Many ethical consults come about because the same circumstance is viewed through different lenses. Kaplan notes conflicts often boil down to communication failure. This is a starting point to prevent conflict from happening in the first place.
Conflicts over withholding and withdrawal of care at the end of life are the most frequent issues that come up in ICUs, says Claudia R. Sotomayor, MD, DBe, clinical ethicist and an adjunct assistant professor at the Georgetown University Pellegrino Center for Clinical Bioethics.
Every day, ethicists participate in ICU rounds, along with the nursing and medical teams, social workers, case managers, PT/OT, nutritionists, and chaplains. If an ethical issue is detected, the ethicist on call proactively assesses the situation. During rounds, the ethicists ask these questions:
- Does the patient have capacity?
- Who is the decision-maker?
- Did the patient present with an advance directive?
- Are there any cultural/religious constraints to the decision-making process?
- Are there any communication issues among the teams, or the teams and the family members?
The ethicist listens carefully, facilitates the communication between all the involved parties, and ultimately gives a recommendation. “These rounds are an excellent way to apply the biopsychosocial-spiritual model,” Sotomayor says.2
This model considers psychological, biological, spiritual, and social factors, and the role they play in understanding illness and healthcare delivery. Using this model, clinical ethicists encourage dialogue between healthcare professionals caring for seriously ill patients.
Sotomayor adds that once ethicists identify the issues, they can aid proper communication and effectively combine all the perspectives of every stakeholder.
- Kayser JB, Kaplan LJ. Conflict management in the ICU. Crit Care Med 2020;48:1349-1357.
- Sotomayor CR, Gallagher CM. The team based biopsychosocial model: Having a clinical ethicist as a facilitator and a bridge between teams. HEC Forum 2019;31:75-83.