Conflict in the care of patients with prolonged stay in the ICU: types, sources, and predictors.
OBJECTIVE
To determine types, sources, and predictors of conflicts among patients with prolonged stay in the ICU.


METHODS
We prospectively identified conflicts by interviewing treating physicians and nurses at two stages during the patients' stays. We then classified conflicts by type and source and used a case-control design to identify predictors of team-family conflicts.


METHODS
Seven medical and surgical ICUs at four teaching hospitals in Boston, USA.


METHODS
All patients admitted to the participating ICUs over an 11-month period whose stay exceeded the 85th percentile length of stay for their respective unit ( n=656).


RESULTS
Clinicians identified 248 conflicts involving 209 patients; hence, nearly one-third of patients had conflict associated with their care: 142 conflicts (57%) were team-family disputes, 76 (31%) were intrateam disputes, and 30 (12%) occurred among family members. Disagreements over life-sustaining treatment led to 63 team-family conflicts (44%). Other leading sources were poor communication (44%), the unavailability of family decision makers (15%), and the surrogates' (perceived) inability to make decisions (16%). Nurses detected all types of conflict more frequently than physicians, especially intrateam conflicts. The presence of a spouse reduced the probability of team-family conflict generally (odds ratio 0.64) and team-family disputes over life-sustaining treatment specifically (odds ratio 0.49).


CONCLUSIONS
Conflict is common in the care of patients with prolonged stays in the ICU. However, efforts to improve the quality of care for critically ill patients that focus on team-family disagreements over life-sustaining treatment miss significant discord in a variety of other areas.
Studdert
David M
DM
Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA. studdert@hsph.harvard.edu
Mello
Michelle M
MM
Burns
Jeffrey P
JP
Puopolo
Ann Louise
AL
Galper
Benjamin Z
BZ
Truog
Robert D
RD
Brennan
Troyen A
TA
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001900:Boston; D016022:Case-Control Studies; D003144:Communication Barriers; D003422:Critical Care / Q000706:statistics & numerical data*; D003657:Decision Making; D034462:Dissent and Disputes; D005195:Family Relations; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D007400:Interprofessional Relations; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011368:Professional-Family Relations; D011446:Prospective Studies; D015203:Reproducibility of Results; D013997:Time Factors