Abstract
Purpose
The purpose of this study is to understand conflicts in the ICU setting as experienced by clinicians and administrators and explore methods currently used to resolve such conflicts when there may be discordance between clinicians and families, caregivers or administration.
Methods
Qualitative case study methodology using semi-structured interviews was used. The sample included community and academic health science centres in 16 hospitals from across the province of Ontario, Canada. A total of 42 participants including hospital administrators and ICU clinicians were interviewed. Participants were sampled purposively to ensure representation.
Results
The most common source of conflict in the ICU is a result of disagreement about the goals of treatment. Such conflicts arise between the ICU and referring teams (inter-team), among members of the ICU team (intra-team), and between the ICU team and patients’ family/substitute decision-maker (SDM). Inter- and intra-team conflicts often contribute to conflicts between the ICU team and families. Various themes were identified as contributing factors that may influence conflict resolution practices as well as the various consequences and challenges of conflict situations. Limitations of current conflict resolution policies were revealed as well as suggested strategies to improve practice.
Conclusions
There is considerable variability in dealing with conflicts in the ICU. Greater attention is needed at a systems level to support a culture aimed at prevention and resolution of conflicts to avoid increased sources of anxiety, stress and burnout.
Similar content being viewed by others
References
Heyland DK, Dodek P, Rocker G, Groll D, Gafni A, Pichora D, Shortt S, Tranmer J, Lazar N, Kutsogiannis J, Lam M, Canadian Researchers End-of-Life Network (CARENET) (2006) What matters most in end-of-life care: perceptions of seriously ill patients and their family members. CMAJ 174:627–633
Azoulay E, Pochard F, Kentish-Barnes N, Chevret S, Aboab J, Adrie C, Annane D, Bleichner G, Bollaert PE, Darmon M, Fassier T, Galliot R, Garrouste-Orgeas M, Goulenok C, Goldgran-Toledano D, Hayon J, Jourdain M, Kaidomar M, Laplace C, Larché J, Liotier J, Papazian L, Poisson C, Reignier J, Saidi F, Schlemmer B, FAMIREA Study Group (2005) Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med 171:987–994
Studdert DM, Mello MM, Burns JP, Puopolo AL, Galper BZ, Truog RD, Brennan TA (2003) Conflict in the care of patients with prolonged stay in the ICU: types, sources, and predictors. Intensive Care Med 29:1489–1497
Burns JP, Mello MM, Studdert DM, Puopolo AL, Truog RD, Brennan TA (2003) Results of a clinical trial on care improvement for the critically ill. Crit Care Med 31:2107–2117
Fisher M (2004) Ethical issues in the intensive care unit. Curr Opin Crit Care 10:292–298
Oberle K, Hughes D (2001) Doctors’ and nurses’ perceptions of ethical problems in end-of-life decisions. J Adv Nurs 33:707–715
Fetters MD, Churchill L, Danis M (2001) Conflict resolution at the end of life. Crit Care Med 29:921–925
Breen CM, Abernethy AP, Abbott KH, Tulsky JA (2001) Conflict associated with decisions to limit life-sustaining treatment in intensive care units. J Gen Intern Med 16:283–289
Poncet MC, Toullic P, Papazian L, Kentish-Barnes N, Timsit JF, Pochard F, Chevret S, Schlemmer B, Azoulay E (2007) Burnout syndrome in critical care nursing staff. Am J Respir Crit Care Med 175:698–704
Miles MB, Huberman AM (1994) Qualitative data analysis. Sage, Thousand Oaks
Coyne IT (1997) Sampling in qualitative research. Purposeful and theoretical sampling; merging or clear boundaries? J Adv Nurs 26:623–630
Denzin NK (2000) Handbook of qualitative research. Sage, Thousand Oaks
Strauss A, Corbin J (1998) Basics of qualitative research techniques and procedures for developing grounded theory, 2nd edn. Sage, London
Creswell J (1998) Qualitative inquiry and research design: choosing among five traditions. Sage, California
Frick S, Uehlinger D, Zuercher Zenklusen R (2003) Medical futility: predicting outcome of intensive care unit patients by nurses and doctors––a prospective comparative study. Crit Care Med 31:456–461
Ferrand E, Lemaire F, Regnier B, Kuteifan K, Badet M, Asfar P, Jaber S, Chagnon JL, Renault A, Robert R, Pochard F, Herve C, Brun-Buisson C, Duvaldestin P, French RESSENTI Group (2003) Discrepancies between perceptions by physicians and nursing staff of intensive care unit end-of-life decisions. Am J Respir Crit Care Med 164:1310–1315
Asch DA, Shea JA, Jedrziewski MK, Bosk CL (1997) The limits of suffering: critical care nurses’ views of hospital care at the end of life. Soc Sci Med 45:1661–1668
Sprung CL, Woodcock T, Sjokvist P, Ricou B, Bulow HH, Lippert A, Maia P, Cohen S, Baras M, Hovilehto S, Ledoux D, Phelan D, Wennberg E, Schobersberger W (2008) Reasons, considerations, difficulties and documentation of end-of-life decisions in European intensive care units: the ETHICUS Study. Intensive Care Med 34:271–277
Azoulay E, Sprung CL (2004) Family–physician interactions in the intensive care unit. Crit Care Med 32:2323–2328
Cook DJ, Giacomini M, Johnson N, Willms D (1999) Life support in the intensive care unit: a qualitative investigation of technological purposes. Canadian Critical Care Trials Group. CMAJ 161:1109–1113
Curtis JR, Shannon SE (2006) Transcending the silos: toward an interdisciplinary approach to end-of-life care in the ICU. Intensive Care Med 32:15–17
Dowdy MD, Robertson C, Bander JA (1998) A study of proactive ethics consultation for critically and terminally ill patients with extended lengths of stay. Crit Care Med 26:252–259
Schneiderman LJ (2006) Effect of ethics consultations in the intensive care unit. Crit Care Med 34:S359–S363
Rego Lins Fumis R, Nishimoto IN, Deheinzelin D (2006) Measuring satisfaction in family members of critically ill cancer patients in Brazil. Intensive Care Med 32:124–128
Danjoux N, Hawryluck L, Lawless B (2007) Cultural and religious aspects of care in the intensive care unit within the context of patient-centred care. Healthc Q 10:42–50
Acknowledgments
This study was supported in collaboration with the Ontario Ministry of Health and Long-Term Care’s Critical Care Strategy as part of the Ethical Issues of Access Program. We would like to thank Tiffany Tomlinson for her help in the interview process and to the hospitals and their staff members for participating in the study.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Danjoux Meth, N., Lawless, B. & Hawryluck, L. Conflicts in the ICU: perspectives of administrators and clinicians. Intensive Care Med 35, 2068–2077 (2009). https://doi.org/10.1007/s00134-009-1639-5
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00134-009-1639-5