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. 2014 Feb;42(2):328-35.
doi: 10.1097/CCM.0b013e3182a27598.

Investigating conflict in ICUs-is the clinicians' perspective enough?

Rachel A Schuster  1 , Seo Yeon Hong, Robert M Arnold, Douglas B White
Affiliations

Investigating conflict in ICUs-is the clinicians' perspective enough?

Rachel A Schuster et al. Crit Care Med. 2014 Feb.

Abstract

Objective: Most studies have assessed conflict between clinicians and surrogate decision makers in ICUs from only clinicians' perspectives. It is unknown if surrogates' perceptions differ from clinicians'. We sought to determine the degree of agreement between physicians and surrogates about conflict and to identify predictors of physician-surrogate conflict.

Design: Prospective cohort study.

Setting: Four ICUs of two hospitals in San Francisco, California.

Patients: Two hundred and thirty surrogate decision makers and 100 physicians of 175 critically ill patients.

Measurements: Questionnaires addressing participants' perceptions of whether there was physician-surrogate conflict, as well as attitudes and preferences about clinician-surrogate communication; κ scores to quantify physician-surrogate concordance about the presence of conflict; and hierarchical multivariate modeling to determine predictors of conflict.

Main results: Either the physician or surrogate identified conflict in 63% of cases. Physicians were less likely to perceive conflict than surrogates (27.8% vs 42.3%; p = 0.007). Agreement between physicians and surrogates about conflict was poor (κ = 0.14). Multivariable analysis with surrogate-assessed conflict as the outcome revealed that higher levels of surrogates' satisfaction with physicians' bedside manner were associated with lower odds of conflict (odds ratio, 0.75 per 1 point increase in satisfaction; 95% CI, 0.59-0.96). Multivariable analysis with physician-assessed conflict as the outcome revealed that the surrogate having felt discriminated against in the healthcare setting was associated with higher odds of conflict (odds ratio, 17.5; 95% CI, 1.6-190.1) while surrogates' satisfaction with physicians' bedside manner was associated with lower odds of conflict (0-10 scale; odds ratio, 0.76 per 1 point increase; 95% CI, 0.58-0.99).

Conclusions: Conflict between physicians and surrogates is common in ICUs. There is little agreement between physicians and surrogates about whether physician-surrogate conflict has occurred. Further work is needed to develop reliable and valid methods to assess conflict. In the interim, future studies should assess conflict from the perspective of both clinicians and surrogates.

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Conflict of interest statement

The remaining authors have disclosed that they do not have any potential conflicts of interest.

Figures

Figure 1
Figure 1
Flow diagram describing enrollment.
Figure 2
Figure 2
Physicians’ and surrogates’ agreement about conflict
See this image and copyright information in PMC

Comment in

References

    1. Abbott KH, Sago JG, Breen CM, Abernethy AP, Tulsky JA. Families looking back: One year after discussion of withdrawal or withholding of life-sustaining support. Crit Care Med. 2001;29(1):197–201. - PubMed
    1. Azoulay E, Timsit J-F, Sprung CL, Soares M, Rusinova K, Lafabrie A, Abizanda R, Svantesson M, Rubulotta F, Ricou B, et al. Prevalence and factors of intensive care unit conflicts: the Conflicus study. Am J Respir Crit Care Med. 2009;180:853–860. - PubMed
    1. Breen CM, Abernethy AP, Abbott KH, Tulsky JA. Conflict associated with decisions to limit life-sustaining treatment in intensive care units. J Gen Intern Med. 2001;16:283–289. - PMC - PubMed
    1. Meth ND, Lawless B, Hawryluck L. Conflicts in the ICU: Perspectives of administrators and clinicians. Intensive Care Med. 2009;35:2068–2077. - PubMed
    1. Studdert DM, Mello MM, Burns JP, Puopolo AL, Galper BZ, Truog RD, Brennan TA. Conflict in the care of patients with prolonged stay in the ICU: types, sources, and predictors. Intensive Care Med. 2003;29:1489–1497. - PubMed

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