Dimensions and Role-Specific Mediators of Surrogate Trust in the ICU

Abstract

Objective: In the ICU, discussions between clinicians and surrogate decision makers are often accompanied by conflict about a patient's prognosis or care plan. Trust plays a role in limiting conflict, but little is known about the determinants of trust in the ICU. We sought to identify the dimensions of trust and clinician behaviors conducive to trust formation in the ICU.

Design: Prospective qualitative study.

Setting: Medical ICU of a major urban university hospital.

Subjects: Surrogate decision makers of intubated, mechanically ventilated patients in the medical ICU.

Measurements and main results: Semistructured interviews focused on surrogates' general experiences in the ICU and on their trust in the clinicians caring for the patient. Interviews were audio-recorded, transcribed verbatim, and coded by two reviewers. Constant comparison was used to identify themes pertaining to trust. Thirty surrogate interviews revealed five dimensions of trust in ICU clinicians: technical competence, communication, honesty, benevolence, and interpersonal skills. Most surrogates emphasized the role of nurses in trust formation, frequently citing their technical competence. Trust in physicians was most commonly related to honesty and the quality of their communication with surrogates.

Conclusions: Interventions to improve trust in the ICU should be role-specific, since surrogate expectations are different for physicians and nurses with regard to behaviors relevant to trust. Further research is needed to confirm our findings and explore the impact of trust modification on clinician-family conflict.

Figure 1

Conceptual framework of surrogate trust in the ICU. This framework illustrates evolution of trust during an ICU hospitalization. Surrogates begin with a baseline level of trust before admission, which is then modified through interactions with physicians and nurses. Changes in trust affect patient and surrogate outcomes during and after the hospitalization. Adapted from Schenker et al (22). Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.