title: Conflict Management Strategies in the ICU Differ Between Palliative Care Specialists and Intensivists.
abstract: OBJECTIVE
  Conflict is common between physicians and surrogate decision makers around end-of-life care in ICU. Involving experts in conflict management improve outcomes, but little is known about what differences in conflict management styles may explain the benefit. We used simulation to examine potential differences in how palliative care specialists manage conflict with surrogates about end-of-life treatment decisions in ICUs compared with intensivists.
  
  
  METHODS
  Subjects participated in a high-fidelity simulation of conflict with a surrogate in an ICU. In this simulation, a medical actor portrayed a surrogate decision maker during an ICU family meeting who refuses to follow an advance directive that clearly declines advanced life-sustaining therapies. We audiorecorded the simulation encounters and applied a coding framework to quantify conflict management behaviors, which was organized into two categories: task-focused communication and relationship building. We used negative binomial modeling to determine whether there were differences between palliative care specialists' and intensivists' use of task-focused communication and relationship building.
  
  
  METHODS
  Single academic medical center ICU.
  
  
  METHODS
  Palliative care specialists and intensivists.
  
  
  METHODS
  None.
  
  
  RESULTS
  We enrolled 11 palliative care specialists and 25 intensivists. The palliative care specialists were all attending physicians. The intensivist group consisted of 11 attending physicians, 9 pulmonary and critical care fellows, and 5 internal medicine residents rotating in the ICU. We excluded five residents from the primary analysis in order to reduce confounding due to training level. Physicians' mean age was 37 years with a mean of 8 years in practice. Palliative care specialists used 55% fewer task-focused communication statements (incidence rate ratio, 0.55; 95% CI, 0.36-0.83; p = 0.005) and 48% more relationship-building statements (incidence rate ratio, 1.48; 95% CI, 0.89-2.46; p = 0.13) compared with intensivists.
  
  
  CONCLUSIONS
  We found that palliative care specialists engage in less task-focused communication when managing conflict with surrogates compared with intensivists. These differences may help explain the benefit of palliative care involvement in conflict and could be the focus of interventions to improve clinicians' conflict resolution skills.
authors.affiliation: 1Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA. 2Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA. 3Center for Bioethics and Health Law, University of Pittsburgh, Pittsburgh, PA. 4Program on Ethics and Decision Making in Critical Illness, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA. 5Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh, Pittsburgh, PA.
authors.forename: Jared
authors.initials: J
authors.lastname: Chiarchiaro
authors.forename: Douglas B
authors.initials: DB
authors.lastname: White
authors.forename: Natalie C
authors.initials: NC
authors.lastname: Ernecoff
authors.forename: Praewpannarai
authors.initials: P
authors.lastname: Buddadhumaruk
authors.forename: Rachel A
authors.initials: RA
authors.lastname: Schuster
authors.forename: Robert M
authors.initials: RM
authors.lastname: Arnold
mesh_terms: D000046:Academic Medical Centers; D000328:Adult; D024362:Advance Directive Adherence; D003142:Communication; D003657:Decision Making; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration*; D008297:Male; D008505:Medical Staff, Hospital; D008875:Middle Aged; D017008:Negotiating / Q000379:methods*; D010166:Palliative Care; D013038:Specialization; D013727:Terminal Care / Q000458:organization & administration*