What we're going to do now is we're going to go through some slides. Neither Lillian nor myself have any conflicts of interest. This is the goal for the next hour. Identify the source of conflict in different clinical scenarios. We're going to characterize different perspectives and practice separating positions from interests, which I talked about before. We're going to brainstorm avenues for consensus and collaboration. We're going to practice crafting language to engage in dialogue. And then, time permitting, you all can share some stories about some experiences you've had with conflict. So this is what the organization of each of the four cases in the next hour is going to look like. Identifying the nature, brainstorming, avenues for consensus, and practice language. And you're going to work at your tables. And after each case, we'll have one table share out how they worked through the case. So case one is a 74-year-old patient with terminal cancer admitted to the ICU with multi-organ failure. He's developed AKI and would require continuous renal replacement therapy as a life-sustaining intervention. The health care team feels initiation of dialysis would not change his terminal cancer prognosis and recommend against it. His daughter demands dialysis and states that not starting it would be the same as killing him. So in your small groups at your table for the next seven minutes, go ahead and work through each aspect of this. So start by identifying the nature of conflict. Who are the disputants? What's the conflict about? Brainstorm positions and interests. What's the what versus the why? Consider avenues for consensus and collaboration. How can you partner? And then practice crafting exact language that you might use to initiate dialogue. And we'll give you about seven minutes or so. And then we'll come back together and share out. How are people doing? We still working? Maybe uh give me a hand if you're if your table is done discussing maybe put a hand up. Oh Good still still going. Okay, keep going Alright, one more minute. Start wrapping up your conversation. You'll get three more bites of the apple after this one. All right, folks. Let's go ahead and bring it back together. I heard a lot of dialogue. Sounds like there was some good conversation, good discussion. Is there a table that would be interested in maybe sharing out how you approach this case? We have four cases and five tables, so pretty much every table is going to go. In the back there. OK, what table are you? Yeah, so it's the health care team versus the family member. Perfect. Pretty straightforward in this one. Yep. And what is the conflict about? And it was like dialysis versus more dialysis. So this idea of continuation of life-sustaining therapies, in this case, dialysis. I agree. Pretty straightforward in this case as well, right? OK, so I'm hearing the what is like this binary dialysis, yes or no, which I sort of described in my talk. And then the why, what I was hearing is from the patient's perspective, it'll help them live longer. And from the health care team, sounds like what you're describing is it may help them live longer, but not necessarily better. First of all, they may not live longer, but they may also not live better. This may actually make them less comfortable or make them worse. Yeah, so I listed some similar ones here in the why. So for the health care team, is this potentially a medically inappropriate intervention? Should we be offering this at all? Is it going to provide the intervention that we think it will and fix what we think is the problem? Will it prolong suffering? Another one I thought about is this idea of health care bias. So we oftentimes will think in a very biomedical way. So this patient is dying. This patient has x, y, z. And I would never do this for my loved one, or I would never want this myself, or I've seen this 1,000 times and it never works. And so we get biased and kind of entrenched in our own kind of thought process. And then for the family, for them it might be an ethical violation. It might be this idea that how can you not offer dialysis? There is no fate worse than death. And doing dialysis forestalls death. It keeps them alive longer, and therefore you must do that. Maybe they're loss averse. They don't want to lose their loved one. And so they really are looking for a way for their loved one to live longer because they're not ready to say goodbye. They're not ready to let go. Or maybe there's prognostic uncertainty. Maybe we haven't been clear about the outcome, or we can't be clear about the outcome. And the family member isn't so sure that their loved one is dying. And so you can imagine there's a lot of reasons why they might raise their hand and say, please do dialysis, besides just like, I want it. And so that's where you kind of did that good work of drilling down. Did anybody, any other tables think of other sort of why responses? Yeah, table two. Gotcha. So maybe we don't have enough medical information. Maybe we haven't conveyed that medical information effectively to the family member. And dialysis, if there's a big brain lesion that's pushing on the brain and you're herniating, dialysis is arguably, I don't throw this word around lightly, but arguably futile. But if it's something else, and they're in, let's say, tumor lysis, and they develop renal failure, maybe dialysis is not so much futile. It's just perhaps medically inappropriate, and you have to negotiate that with the family. Great. Avenues, back to table six. Avenues for collaboration. Yeah, yeah, a lot of times you'll hear language like they're, they're not thinking rationally or they're behaving irrationally and, and I like to say that it's not so much that families are irrational, they're just human, right? They just are looking for a way to cope with what they're experiencing. Other tables, had any other ideas for avenues for consensus? I like that one there. Yep. In the back table. I can't read the number five. Yeah. Anybody else? Okay, excellent. So yeah, one more in the back. Yep. So you all hit the first two, which is this idea of clarifying the medical condition, which was said in the back, making sure that everyone understands the severity of the illness, and then learning about the patient's values and preferences, right? And learning about not just the family members' values and preferences, but the patient's values and preferences. So spending time really drilling down to understand who they are, what makes life worth living, what provides value in their life, what are they hoping for, what do they wish, right? What are they willing to endure? All of those questions can be really helpful in helping to guide. And then one other thing that I thought about was this idea of a time-limited trial. So maybe there's an opportunity here for us to partner with the family and say, I'm worried that dialysis isn't going to be helpful. But maybe we give it a try for x number of days and see how it goes, with the understanding that if we don't see him getting better, we're going to stop the dialysis. And so giving the family sort of that olive branch of saying, we're going to give it a try. All right. Language to initiate dialogue. Yeah, I have no problem at all with trying to help work through the medical aspects. I think that one thing that I really lean on that has been helpful to me in my career is really spending time validating the lived experience of the loved one before I get into the medical. And so when I approach a case like this, I've crafted some stock language that I oftentimes will use. I'll say things like, it sounds like you really care about your dad and are trying to make the best decision for his care, because this can't be easy for her, right? She's not just like willy nilly being like, give dialysis, right? Would it be okay for me to share more about what's going on with his condition? So asking permission to share that information before you start talking about kind of what you described very well. And then, you know, in the vital talk world, we talk about this idea of being in a different place and using human language, not medical language. So getting away from the like, the dialysis does this, the dialysis does that. It's really this problem that's the primary problem, not the renal failure, but really I'm worried we're in a different place and that your dad may die even if we start dialysis. So very straightforward and very clear. And then again, asking permission, would it be okay if we talk about what's important to your dad given how sick he is and hearing what's important to him. And I, it's a subtle change from the what I want. I think, does anybody want to die? I mean, other than like someone who's severely depressed and have suicidal ideation, like nobody wants to die. Nobody wants to be critically ill. No one wants to be on a ventilator. And I think we use that language a lot, what I want, right, or what he would want. And I encourage you to get away from the I want, right, and to think more about what's important to him because what's important to you can be consistent no matter how sick you are. What I want kind of changes based on circumstance and we can't possibly wrap our minds around this idea of what I want. And then I offer a recommendation. So I ask permission and then one option for it would be for us to try dialysis for a short period of time, perhaps a few days, and see if his condition improves. If it does, that would be wonderful. If not, we could regroup and talk more about focusing on his comfort and stop the dialysis and other treatments that are keeping him alive. How does that sound? And then allowing them to sort of ascent or descent on that recommendation. Yep. I think that's really important because I think we oftentimes think in terms of days and hours and we forget what weeks and months are gonna look like especially for survivors of critical illness. It's hard for us to prognosticate but being able to put some boundaries around that sort of and frame it for them I think is important. Yeah, I mean, I think the literature would tell us that people can endure a great deal of physical suffering and physical disability long term, and they can accommodate to that new reality and live very productive, happy lives, and so I think that physical impairment is less relevant, but consistently people, when they talk about what they value, they value their cognitive faculties, their ability to be with family, to be able to engage with people, to be awake and alert and to be able to interact, and so I think when I'm worried about someone who may not regain sort of their cognitive function, I think it's important that we be honest about that, and some people will say, well, isn't that coercive, and I think that everything we do is coercive in one way or another, there's no neutral, right? Anytime we use language and speak to people, there's naturally bias in how we frame things, but I do think that's important. All right, we're going to jump to the second case, I'm going to hand it over to Lillian. I just want to emphasize something that was in the slides that Josh pointed out, we ask permission to give the recommendation, we ask before we pivot every time, it gives some agency back to the family members, so there's this, so that we can layer on to the next skill for the next case. So the next case is a 62-year-old patient who's 11 months out from a liver transplant, she's been in and out of the ICU four times now with repeated complications from the transplant, is dependent on hospitalizations, she basically really hasn't made it all the way home. So she's actually shared now filing with the medical ICU team, she's extremely exhausted, she's tired of being in the hospital, and she doesn't want to come back and forth anymore between floor, ICU, floor, ICU, even if it means that potentially that they may die. So her, the only hesitation is letting down the transplant team. So now you approach the transplant team and share this information, that this is what the patient said, and the transplant surgeon responds, I will never give her permission to die, that is not my job. My job is to ensure that the organ is put to good use. So I know not everyone works in the transplant center, this is not uncommon when dealing with certain transplant specialists, and so our job right now is going to be the same. Identify the nature of the conflict, who are the disputants, what is the conflict about, brainstorm our positions of the what, the why, consider avenues for consensus and collaboration, and more importantly is the sentences, how would you craft how we're going to interact together to be able to get through this. So again, you have seven minutes, and then we're going to call on the tables to get through the case. Okay. Okay, let's see whether we can move on with this case. Okay, so we're gonna wrap it up. Okay, so, we're gonna just go call around the tables. We're gonna just run Robin through all the different tables. So who are the disputants? Table, okay, table five wants to go first. Who are the disputants? Sounds good, perfect. And then what is the conflict about? Yeah, sounds good. So basically, what is the purpose of the transplant from the transplant team's perspective, the survival of the allograft versus actually having patients have autonomy over their own choice of what medical care they get? Wonderful, thank you team five. Team four, table four. What is the positions of the interests and the why? Sounds good. And then so what we were thinking for this particular case was from the ICU team, along with the patient's perspective, we want to make sure that we're providing the right care that the patient wants and have it in alignment, right? And then from the transplant team, the question also is the why, why now? Why now 11 months later when potentially it could be something that they think could actually be survivable, this infection is survivable. Okay, so table three. What avenues for consensus and collaboration do we have now that we've explored both perspectives? Yeah, wonderful. So what I'm hearing you say is that part of it is taking the values and perspectives of both parties, both the transplant team's perspective from a medical and also statistical and performance level for their particular organization versus the patient level values and outcomes and quality metrics that they're actually more interested in. And see if you can find something that's common ground where everyone can agree on for the quality of life that the patient's currently expecting and the family's currently expecting. And so just to clarify those concerns and those tensions between what post-transplant care really actually does look like on a day-to-day basis. Sometimes you don't really realize and when you say yes on the dotted line to what that journey actually looks like 11 months later or 12 months later. So what language are we going to use to get there to resolve this tension between the transplant patients and their family and the team? What sentences did we come up with? Table two. There's a lot of people at table two. I'm going to highlight some really great things in that entire sequence, just for clarity for everyone. The use of specific words like we and together. One thing to validate both the transplant team's general summary of their perspective and also the patient's perspective of this was for a goal to live more outside the hospital and also that this has not happened. And so now that we have goal discordance and to name it really explicitly. And then to also offer, would it be all right if I made a recommendation for what we could do and then to be explicit about time limited trial, meaning like, let's, let's all agree that why don't we try for the next two weeks, a particular outcome and being really specific about what the outcome looks like. And then from there, reevaluate and have a very staged plan sequence so that as we all change service, right, we all know our teams change, especially in the ICU, that we're always going to have a continuity of plan in general. And then you also may be bringing other people in as well. And so I'm, so things that we came up with was, it sounds like you feel really strongly that the patient should be fighting, so this is to acknowledge the perspective of the transplant team. Can you tell me more about why that's important? And so you also had some exploring in your version and then it's really hard to allocate to a patient and see, to see the, the organ fail. And I'm worried, we are worried, right, this is not a survivable condition. So can you help me understand your view on the patient's global prognosis and would it be helpful if I take a lead on the conversations with the patient around their medical decision making? And then that allows you a time that we're all going to, we're all on the same team together. There is no, so the three, the three parties can actually come together and actually have a patient centered outcome. And again, anchoring what we can agree upon is through the exploration that all of you have done through the exploration of the values and the sequencing is really important. Go ahead. Okay. So we're going to move on to the, just go ahead, just go right to case four. Okay. We're going to skip to case four, which I think is more valuable than case three, just in the interest of time. And then at the end, if we have a couple of minutes, I'll just show you the slides on case three, which is really about an adverse event and how you disclose an adverse event or a medical error to try to work with families and collaborate. So case four is 89 year old. So excellent work everyone. So thank you from case two. This is 89 year old patient with end stage dementia, admitted to the ICU with a GI bleed. She's in hemorrhagic shock. You aggressively resuscitate her, but she remains critically ill. She needs additional lifesaving therapies, including intubation. She's unlikely to survive. She has two sons who share the responsibility as the surrogate decision makers. One son articulates that his mother would never want to be in this condition and requests comfort care now. The other son disagrees completely emphatically saying, I've been the one taking care of her mostly. She and I had a conversation last month and she said that she had faith that she would get better. I know she would want to fight and stay alive. I believe in miracles. Don't you? And so we are, same thing, nature of the conflict, brainstorm the positions, consider avenues for consensus and collaboration, and craft the language. So I'm just going to go back, that way you can see the case. But I think it's going to be afterward, after the break. Okay, let's come back together and, okay, let's see. We'll start back with table six again. I'm going to go over in reverse again. So table six, who are the disputants and what is the conflict about, if you're willing to? So the disputants, we talked about this for a moment. Thank you. We feel like the disputants are brother versus brother and we talked about whether the health care team kind of entered into that conflict as one of the disputants or on the side of one of the disputants. It seems like so far, though, I would say the disputants are brother versus brother. And the conflict is about. No, we're going to go to, we'll share the wealth. So this is a, and then obviously you always wonder for their two positions. What can she do in the future? Is it the what is are we going to continue right are we going to continue care like one one's comfort The other one who says I believe in miracles And so then what's the why that we're wondering about? Okay And what are you hypothesizing in your mind Okay Right Right so we have one perspective that we're wondering whether it's inconsistent with what the mom's values are right So the patient's values is which of these surrogates is actually Maybe more accurate in actually their perceptions, or maybe they're both accurate, and that's probably the reality They're both accurate and the question is going to be also where their values sort of coming through And so we don't know we were gonna have to explore a little bit to find out well Which both how can both perspectives be true given whether their mom has or has not had other excellent? Explanations to them yes We Got forced into the conflict because they said or at least they thought they said don't you believe in miracles also? So and this was something that I thought was interesting well, I would I'm fascinated by what other people's responses may have been in that scenario because as For I speak for I right I do not and thus right Certainly wouldn't have said that out loud giving. That's how they felt, but they forced us into a dialogue and Right we can address that towards the end if we'll hold that first just so we can get through the case So what avenues for collaboration consensus might we find with two people who are told totally polar opposites? And who've now dragged us into this conversation so table three We Talked about getting risk and ethics involved And to just I think better exploring. I Think the perspectives one of each son and then like why they feel that way and then kind of that one-to-one Pull aside you were mentioning earlier trying to understand and maybe there's some emotional or past history Component to either that needs to kind of be worked through and trying to come to a consensus Sounds good. So who we do who do we actually care about the most is to bring the patient back to life, right? So being really careful as we get into the next part, which is how do you craft the language? We care we care a little bit about what each person's perspective is right two different sounds We need to support them emotionally and cognitively and value wise But the person actually is missing in the room that probably the most important is the patient and so part of the questions you're going to now for is what language do we actually use to initiate the dialogue of how To bring them the patient the mom's values into the room table for what language specifically did we try? So what we thought of First of all, you want to find out whether there was an enduring part of attorney Has the patient located any one of the sons as an enduring part of 10? You can actually make decisions on behalf of Because that would be more appropriate Second thing is the second son who is actually disputing He's actually said that he had a conversation with her last month and she wanted everything to be done But the patient is already having in stage con in state dementia and we don't know whether he's actually talking from an emotional point of view or not. So so the language which you want is in spite of in spite of all the Discussions she had if this one the disputing son is insisting on all full management And which is actually in case futile management we can actually In that case will be you talk to each son separately just to get their perception and why he thinks that That's her wishes and why the other son has a different view Is that one of the cases that you talk to everyone separately as you mentioned earlier? You might I personally actually generally try not I actually don't usually as a rare set situation I think that you have to separate people So in this particular case just so we can resolve it and then we can move on to some of the questions you had I Can tell you both really care about your mom and are trying to make the best decision for her care Even though they feel really different. You said that you wouldn't she wouldn't want to be in this condition Tell me more about that and has she ever spoken about what she values and what do you think given the circumstances of what? She's going through right now What do you think would be most important to her right now in this moment, right? Because if she's imminently dying on you tonight from her at hemorrhagic shock This is a very different conversation, right? Versus whether she's in some kind of portion of the critical illness then to the other side It sounds like you're really hopeful from a miraculous recovery. What would a miracle look like for you? Is there anything else you're hopeful for or tell me more what you think a miracle might look like right now? Because I mean, I don't know about you and me But I actually don't know what miracles look like and they're very context specific and also rare and special And so if we could have one it helps people realize that sometimes they're just scared and just relying on their faith other times they actually know exactly what the miracle might look like for them and you don't know and so exploring in both of these situations Helps both parties understand the danger to me in this situation of separating them too early When is is that maybe they we all need to join the three of us all need to join on her best behalf And so I think until you see them literally get to maybe more physical or more dangerous more threatening kind of things I probably wouldn't separate them These are very easy to join together with them So that we can all name that we all want to do the right thing by your mom We're gonna slow this conversation down so that we all can feel okay here And then they're like, okay, and then you can address separately And is it and even as soon as I even ask permission, is it okay if I talk about this? I know that maybe you might not always agree, but it's helpful to us as the team to hear both of your perspectives Could you both just like be willing to be in the room together because I've had people who have come to fistfights almost right? But you can just knowledge do it for us if you care about us and your mom. We want to care for your mom Can you just be okay for like five minutes while I talk to the other party? Yeah, it's rare that you have to separate people and it's only when the space has become unproductive And you can't get anywhere that you really need to like separate people out if the if the two sons are getting along and they're And they just have difference of opinion But but they're able to talk to each other and engage with each other and listen to each other There's no reason to separate them And I think what I want to what I want to hammer home on these Particularly these slides that are what would you say is you'll notice that? Very few very little of the language is actually medical Language and I think that we have a tendency in the critical care world as physicians to To think very much in terms of Process, what do I need to do to be able to do something else? And I think that what what we do in the palliative care world, I think is essential as it's very relational It's about building consensus and building relationships and so you'll notice that a lot of this is not about like trying to explain to someone the medical information trying to Trying to make sure that they understand the condition and the choices, but it's much more about trying to elicit values and preferences and goals and And really understand them on a human level and that's what allows you then to be able on the back end to say This is what I think makes the most sense for your loved one based on what you have told me. What do you think? It makes it a much more palatable way for families to sort of come to consensus and be able to sort of Achieve a goal that for them feels like a win-win The one other thing I would just say with your question about miracles My sort of like token response when someone says don't you have faith or don't you believe in miracles is to say I Believe that there are things that happen that I can't explain But I can't make medical decisions based on The possibility of a miracle I have to use the information in front of me But tell me a little bit more about what a miracle means to you So I kind of put it back on them to understand because a miracle it is context specific and it means different things to different people that we'll then have a discussion about potentially changing the code status or having some other conversations. Is it important to be specific at that time maybe at the primary conversation with the patient's family to say we'll try this if that works great but if not I find myself saying and maybe this is just this optimism that I have I don't know but they just say okay we'll try that and if it doesn't work we'll have a different conversation but I feel like I'm not being as specific as I should be about that other conversation which is not yeah there's a great article by Taylor Lincoln on time-limited trials and the specificity of not only like what are we looking for like in terms of is it coming off one blood pressure medicine is it ventilator settings cut in half I mean you should have to be explicit like what are you as a medical team that we round every day what are we looking for to say we made a micro progress that we would want to continue and then also the time to so like reasonably speaking there's a range somewhere within the three to five day range we should see this and so yes you had to be specific both on the time and exactly what you see so it's not fuzzy so it's clear because then we will we will reconvene with you and let you know how things are going at that three-day interval so that we can make the next should we do another time limit trial or will we have greater clarity I think it depends again on the situation or how early you're doing your TLT's that makes anything sometimes I say the patient will declare themselves at that time and then we will see what is declaring what is declaring themselves mean doctor right like that's what you'll get back and then you'll you'll want you'll have to explain it anyway so but we oh one more okay one of the other things for a time-limited trial is sometimes allowing the patient's family to have that grieving acceptance period which frequently does take about three days and there are some families that I'm running through the numbers and we've got four down down intervals on all of the organs and one up interval and I also try to get them comfortable with the concept of ambiguity yes yeah it's a great very great point thank you I think we're gonna we can answer questions offline but we're gonna move on with the agenda I think

conflict resolution

clinical scenarios

consensus building

patient values

compassionate communication

family involvement

empathy

decision-making

healthcare settings