title: Investigating conflict in ICUs-is the clinicians' perspective enough?
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.
  
  
  METHODS
  Prospective cohort study.
  
  
  METHODS
  Four ICUs of two hospitals in San Francisco, California.
  
  
  METHODS
  Two hundred and thirty surrogate decision makers and 100 physicians of 175 critically ill patients.
  
  
  METHODS
  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.
  
  
  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.
authors.affiliation: 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.
authors.forename: Rachel A
authors.initials: RA
authors.lastname: Schuster
authors.forename: Seo Yeon
authors.initials: SY
authors.lastname: Hong
authors.forename: Robert M
authors.initials: RM
authors.lastname: Arnold
authors.forename: Douglas B
authors.initials: DB
authors.lastname: White
mesh_terms: D001291:Attitude of Health Personnel; D003220:Conflict, Psychological; D003657:Decision Making; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D010820:Physicians; D011446:Prospective Studies