Clinical Investigations

Investigating Conflict in ICUs—Is the Clinicians’ Perspective Enough?*

Schuster, Rachel A. MD^1,2,3; Hong, Seo Yeon⁴; Arnold, Robert M. MD⁵; White, Douglas B. MD, MAS^1,2,6

¹Program on Ethics and Decision Making in Critical Illness, University of Pittsburgh, Pittsburgh, PA.

²Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Laboratory, University of Pittsburgh, Pittsburgh, PA.

³Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA.

⁴Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA.

⁵Department of Medicine, Division of General Internal Medicine, Section on Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA.

⁶Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA.

* See also p. 461.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Drs. Schuster (1R01HL094553-01) and White (5T32HL007563) received support for article research from the National Institutes of Health. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: [email protected]

Critical Care Medicine 42(2):p 328-335, February 2014. | DOI: 10.1097/CCM.0b013e3182a27598

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.