How doctors manage conflicts with families of critically ill patients during conversations about end-of-life decisions in neonatal, pediatric, and adult intensive care,Intensive Care Medicine

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How doctors manage conflicts with families of critically ill patients during conversations about end-of-life decisions in neonatal, pediatric, and adult intensive care
Intensive Care Medicine ( IF 27.1 ) Pub Date : 2022-06-30 , DOI: 10.1007/s00134-022-06771-5
Amber S Spijkers _{1,

2} , Aranka Akkermans _{1,

2} , Ellen M A Smets _{1,

2} , Marcus J Schultz _{3,

4,

5} , Thomas G V Cherpanath ₃ , Job B M van Woensel ₆ , Marc van Heerde ₆ , Anton H van Kaam ₇ , Moniek van de Loo ₇ , Dick L Willems ₈ , Mirjam A de Vos ₉

Affiliation

Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Location AMC, Meibergdreef 9, Amsterdam, North Holland, 1105 AZ, The Netherlands.
Amsterdam Public Health research institute (APH), Amsterdam UMC, Amsterdam, The Netherlands.
Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.
Nuffield Department of Medicine, University of Oxford, Oxford, UK.
Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
Department of Ethics, Law and Humanities, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
Department of Pediatrics, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.

Purpose

Intensive care is a stressful environment in which team-family conflicts commonly occur. If managed poorly, conflicts can have negative effects on all parties involved. Previous studies mainly investigated these conflicts and their management in a retrospective way. This study aimed to prospectively explore team-family conflicts, including its main topics, complicating factors, doctors’ conflict management strategies and the effect of these strategies.

Methods

Conversations between doctors in the neonatal, pediatric, and adult intensive care unit of a large university-based hospital and families of critically ill patients were audio-recorded from the moment doubts arose whether treatment was still in patients’ best interest. Transcripts were coded and analyzed using a qualitative deductive approach.

Results

Team-family conflicts occurred in 29 out of 101 conversations (29%) concerning 20 out of 36 patients (56%). Conflicts mostly concerned more than one topic. We identified four complicating context- and/or family-related factors: diagnostic and prognostic uncertainty, families’ strong negative emotions, limited health literacy, and burden of responsibility. Doctors used four overarching strategies to manage conflicts, namely content-oriented, process-oriented, moral and empathic strategies. Doctors mostly used content-oriented strategies, independent of the intensive care setting. They were able to effectively address conflicts in most conversations. Yet, if they did not acknowledge families’ cues indicating the existence of one or more complicating factors, conflicts were likely to linger on during the conversation.

Conclusion

This study underlines the importance of doctors tailoring their communication strategies to the concrete conflict topic(s) and to the context- and family-related factors which complicate a specific conflict.

中文翻译：

在讨论新生儿、儿科和成人重症监护中的临终决策时，医生如何处理与危重病人家属的冲突

目的

重症监护是一个充满压力的环境，团队与家庭之间的冲突经常发生。如果管理不善，冲突会对所有相关方产生负面影响。以前的研究主要以回顾性的方式调查这些冲突及其管理。本研究旨在前瞻性探讨团队-家庭冲突，包括其主要议题、复杂因素、医生的冲突管理策略以及这些策略的效果。

方法

一家大型大学医院的新生儿、儿科和成人重症监护病房的医生与重症患者家属之间的对话，从怀疑治疗是否仍符合患者最佳利益的那一刻起，就被录音了。使用定性演绎方法对转录本进行编码和分析。

结果

团队-家庭冲突发生在 101 次谈话中的 29 次 (29%)，涉及 36 名患者中的 20 名 (56%)。冲突大多涉及不止一个话题。我们确定了四个复杂的背景和/或家庭相关因素：诊断和预后的不确定性、家庭强烈的负面情绪、有限的健康知识和责任负担。医生使用四种总体策略来管理冲突，即内容导向、过程导向、道德和同理心策略。医生大多使用以内容为导向的策略，与重症监护环境无关。他们能够有效地解决大多数对话中的冲突。然而，如果他们不承认家人暗示存在一个或多个复杂因素的线索，那么在谈话过程中冲突可能会持续存在。