Okay, so I will be talking about the causes of clinician-family conflict, and then Dr. John will come in and talk about resolution mechanisms. And I'll be focusing on the adult ICU context to kind of build on what Alex talked about in the pediatric context. These are my financial disclosures, none of which pose a conflict with what I'll be presenting. And what I'd like to do is basically cover two broad points. First, I'd like to highlight a common but flawed way or a mindset that clinicians sometimes have when they think about what actually is the root of clinician-family conflict in ICUs. And then I'll present a framework to diagnose the causes of conflict with the hope that this will allow more effective conflict resolution. And I'm going to do it in a way that hopefully is very straightforward and is the kind of thing that you could teach to your trainees on rounds as a sort of a differential diagnosis to work through in the moment when you're experiencing conflict with a family. Okay, so why are we even talking about this? Well, if you're not a clinician in an ICU setting, let me just tell you that clinician-family conflict in that context is quite common. These are just three studies from the last 20 years showing that the prevalence of conflict between clinicians and families about end-of-life care or end-of-life decision-making ranges from about 27% in Europe to 63% in a cohort study that we did in actually here in San Francisco Bay Area. So pretty common. So something we need to be able to address like we need to be able to address putting in a central line. And so what is this mindset that I was talking about? Well, you know, sometimes, especially amongst less experienced clinicians, something like this happens. They walk out of a family meeting in which they're recommended transitioning to a comfort-focused plan of care. The family said, yeah, we're not going to do that. You know, keep going with full life support. And the conclusion from the trainee or the clinician is they just didn't understand how sick their loved one is. And so the next time I go in there, I'm going to say it louder and I'm going to say it slower and that's going to work. And so that mindset is the mindset that I want to just make sure you disabuse yourselves of very quickly. That's a mindset that's sort of a rational actor way of thinking about what's going on. And the idea there being that all that matters to good decisions is good information and good information about prognosis, good information about options, and with that, good decisions will reliably follow. That's not the case. Okay? There are many, many, many studies from experimental psychology discounting that and showing that there are other considerations that come into play. And those kinds of considerations are not just the cognitive aspects of what it takes to make a good decision, but emotions can strongly influence how people deliberate and make decisions, and psychological and moral considerations can strongly impact how families decide for critically ill loved ones. And so that we, along with Nick Dion-Odom, we wrote a paper in JAMA in which we kind of laid out this tripartite way of thinking about how families make decisions and what they need to be assisted in that process. So here's the framework. If you find yourself faced with a family that seems to really disagree with, for example, your recommendation about goals of care in the ICU setting, ask yourself three broad questions. Is it a fact issue? Is this a feelings issue? Or is there some psychological or moral issue that's getting in the way of decision making? And the kind of questions that populate each of these are, under facts, does the family have a different understanding of what's going on with their loved one than I do? Is it really just they really don't understand what's going on, like the interns often think it is? Or is there something else going on? Do they actually understand it? Are they so overwhelmed that they just can't understand it so that more information is not going to help? Their information processing circuits are on hold until the flooding in their brain subsides. Or do they distrust clinicians? And Alex was already talking about this. Do they distrust clinicians so much that no matter how many times you say something, they're not going to believe you because of either past negative experiences, experiences of discrimination, or just experiences where the family got or the clinicians got it wrong? And then finally, this class of things that I'll call psychological and moral considerations. So does the family have some psychological barrier to doing what appears to be consistent with the patient's values and preferences? Or is the family entirely articulating what the patient would choose and it just runs against what the clinician thinks is good medical practice or what's consistent with his or her deeply held personal beliefs? And so I really want to make sure that we don't even implicitly make the mistake of saying that this is really always about the families, right? Quite often we are bringing our own stuff to these conversations. Maybe we're too certain that the prognosis is poor when in fact there is actually a little bit of room for prognostic uncertainty. Or maybe this case is pushing our buttons in a particular way and we need to get sort of a handle on that before we move forward. Or finally, as I said, maybe the case is pushing up against the boundaries of what we think is acceptable medical practice and so there's a conflict between the family's conception of the good and ours. So let me just touch on a couple fact-based causes of conflict. The first is what we've already talked about, which is this notion that sometimes families just don't understand what the patient's prognosis is and how poor things are. So this was a cohort study we published now seven or eight years ago in which we found that 31% of surrogates in the ICU setting on ICU day five after a clinician family meeting had a significantly more optimistic expectation about the patient's prognosis than the clinician. So more than 20% higher expectation for chances of survival. Obviously a setup, if the family thinks the prognosis is good, the doctor thinks the prognosis is bad, that that's a conflict ready to happen. And you might think, well, again, this is just about the families not comprehending our empathic clear prognostic statements, but a number of investigators, including my group have audio recorded clinician family conversations and really just look to see what are doctors saying in these meetings and other clinicians. And what we found is that there was no discussion of patient's prognosis for short-term survival in 40% of conversations and no discussion of their chances for long-term survival in almost 90%. So some real and important omissions of the kind of prognostic information that families need to make good informed decisions. Other factual bases or causes for conflict may be things like the family just doesn't understand what the surrogate role is. They think that they should be making the decisions that they want for their loved one rather than the decisions their loved one would make for themselves. And a factual clarification may be a benefit there. And another one that I increasingly am finding is that sometimes families just don't actually know that there are other permissible options than full intensive treatment in the ICU context. You may assume, well, they know that we can stop or they know that we can stop after a few days. But if you don't really flesh out what that option looks like, it may just be too fuzzy for families to really grasp what a comfort-focused care pathway looks like. All right. Let's transition to emotion-based causes of conflict. And here I'm just going to speak much more from the perspective of decision-making and decision psychology rather than particulars of the ICU setting. There is a great deal of literature from the fields of decision sciences and decision psychology that intense negative emotions like fear and anxiety really affect how people think and reason. And so, for example, people, when they have experimentally induced severe anxiety in people, which is an interesting lab-based experiment to do, they found that people have lower ability to recall information and organize this information. They scan alternatives, i.e., things like treatment options, in a more haphazard fashion. And they select options without considering the alternatives carefully. Think about this with surrogates making decisions between life support and comfort-focused care. And they process persuasion arguments less thoroughly. And what this means is a persuasion argument is akin to a recommendation. And so the idea here is that families may not actually be able to hear our recommendations when they are in this sort of acutely flooded, highly stressed emotional state. The other thing that's important is that sometimes the words that we say are themselves incredibly distressing. And there is a whole field focused on what's called defensive processing of personally relevant health messages. And the idea here is that the more threatening a health message is, like your loved one has a very poor prognosis, the more likely people are to downplay the seriousness of the risk, question the accuracy of the threatening information, or process that information in a biased fashion. And in fact, we did see this in the JAMA paper I mentioned earlier. When surrogates were much more optimistic than the clinicians about the patient's prognosis, we asked them, why do you hold this belief? And the kinds of answers we got very much tracked with defensive processing. So some surrogates felt or challenged the accuracy of the prognostic statement by saying things like, I know him more than what the doctor do. And when you don't know a person, it's pretty much, this is what I read in a book. And I'm not reading a book. I'm reading from experience. Others just said, I heard what the doctor said, but I can't do that. I guess I understand that he might die, but that's not something I'm quite able to look at right now. So imagine going in and sort of banging them over and over again with prognostic information when really it's just the acute emotional strain of seeing your loved one near death. Probably not going to work. And then I think it's really important to highlight that, and Alex touched on this, prior experiences of trauma in general and discrimination in particular also may predispose to conflict in the ICU setting. And Rachel Schuster led a study in which she found that surrogates having previously felt discriminated against in the healthcare setting, so different hospitalization in the past, were significantly more likely to report conflict with clinicians around surrogate decision making in the ICU with an odds ratio of 17.5. So a very strong effect of prior experiences of discrimination on the ICU setting. And I put a couple other papers up here, one by Megan Morris that just came out a couple weeks ago around her experiences with her father who had a disability in the ICU context and the ableism that she felt was imbued in the decision making. And then a really nice paper by Deep Ashina looking at decision making in the ICU context through the trauma-informed care lens. And I think if we talk about interventions, that's a very promising path forward. And then last, just a couple slides on the psychological and moral causes that I mentioned before. A number of studies over the last several decades have interviewed families about their experiences with decision making in the ICU setting and what was hard for them. In particular, the things that jumped out were not, I just couldn't get information from doctors. It was much more in the space of things like, it's just incredibly hard to make a decision to stop life support for someone that you love. And Yael Schenker led a really nice project in which the interviews revealed sort of the main theme that surrogates experience significant intrapersonal conflict between their desire to act in accord with their loved one's values and not wanting to feel responsible for their loved one's death. And so this gets at the idea of guilt or avoiding the perception of blameworthiness. That is another very distinct reason that there may be conflict in the ICU setting. We've also found, and I think those who practice know that religious beliefs can substantially influence end-of-life decision making. We found, again, in the JAMA paper in 2016, that one of the main reasons that some families were optimistic was a belief that the outcomes were determined not by medical facts and what the doctor did, but by their religious convictions. And so they said, I believe the doctor would only believe in what he can do for my son. I believe what he can do and what God can do. And then finally, and this is my last point, sometimes, as I mentioned before, there's just a deep moral disagreement about what's best for the patient. And this is a paper by Zeke Emanuel. If you want to think more about best interest decision making, Zeke outlined a number of different ways that people conceive of the good. And these are just two of them, but these two ways are diametrically opposed and point to very different decisions in the ICU context. And so one, I think, fairly common way of thinking about what's the good for many physicians is what Zeke described as an affective approach to life, is that life's value arises from our ability to interact with other people and form emotional loving relationships. And when that's gone, that is a life that need not be continued or extended in the ICU setting. However, there are traditional religions in the United States, Orthodox Jews, conservative Christians who hold a very different belief that is often called something like vitalism, in which life is valued in any form, it's precious in any form, and its value is measured in milliseconds, such that if you can continue the life with life-sustaining treatment, you should, irregardless of other people's perceptions of the quality of life. So that's a deep moral disagreement, and you can have families advocating faithfully on the patient's behalf, and clinicians saying, this seems to butt up against what's appropriate medical care. All right, so let me just end with putting the framework back up there. Remember, decisions are not just influenced by cognitive issues. There are also emotional considerations and psychological considerations that come up. When you're thinking about this differential in the ICU context, and you're in a family meeting and you're feeling conflict with families, ask yourself, is this a factual issue? Is this an emotion or feeling-based issue, or is this a deep psychological or moral issue? And then finally, don't forget about your own stuff contributing to the mix. Thanks very much.

clinician-family conflict

ICU setting

causes of conflict

conflict resolution

perspective