Hello, my name's Adam Leighton. I'm an assistant professor of anesthesia and critical care medicine and emergency medicine at the Johns Hopkins University School of Medicine. And I'll be talking about communication tools for conflict management in the intensive care unit. I think we all can acknowledge the conflict is common in the ICU. It's a high stress environment and there are physical discomforts, emotional suffering, spiritual distress, and financial hardships, both for the patients and their families, as well as for the healthcare providers. Sleep deprivation, bad food, and social isolation are all common. And in the midst of these challenges, we often need to make high stakes decisions quickly. Everyone deals with that type of stress differently based on their personality, cultural background, prior experiences, and interpersonal relationships. There aren't inherently right or wrong ways to deal with stress, but often we see interactions go poorly and conflicts arise in the ICU. They can undermine the therapeutic partnership and prevent us from achieving the best outcomes for our patients. A lot has been written about conflict management in the ICU, but today I want to discuss two key concepts that come from outside of the critical care literature. The first, which comes from the world of business, is the idea of understanding conflict management as a type of a negotiation. The second, which comes from the world of mental health, is the idea of trauma-informed care. These are two popular books about negotiation strategies. Both are great, full of useful insights and are easy reads, and both have made me a better intensivist. I'll highlight a few ideas from each, but I'd encourage you to read them both fully. In his book, Shell defines a negotiation as an interactive communication process that takes place whenever we want something from someone else or another person wants something from us. That applies to most of my conversations in the ICU. And often we find that we want different things. Sometimes it really does come down to a zero-sum game where either I get what I want or you get what you want, and there is no common ground, but that's rarely the case. And so our objective in a negotiation is to align our interests to work towards a common goal. Useful concept here is the difference between positions, the represented by triangles in the schematic, and interests represented by the circles. Positions are the things that we say that we want. In the ICU, this could be something like us asking a patient to consent for a procedure, us asking a consulting service to come and see our patient, or even a patient just asking his nurse to adjust his pillows. Interests, on the other hand, are the things we really want to accomplish. These are our hopes and goals in care. Often, conflict arises when we focus on our positions without addressing how those positions do or do not serve our underlying interests. Reframing discussions to focus on interests instead of positions can be a powerful way to resolve conflicts. Let's talk about an example. Imagine a 74-year-old woman who's on ICU day 15. She was admitted to your unit following an exploratory laparotomy for a bowel perforation with peritonitis. She's had a long, complicated ICU course already. She has septic shock and an acute kidney injury that have resolved, but she still has ventilator-dependent respiratory failure, ICU-acquired weakness, and delirium that persist. She failed a trial of extubation yesterday, and it wouldn't be crazy if you thought it's time to start thinking about a tracheostomy for her. And so at this point, the ICU team might reasonably approach the family and say, we'd like your permission to obtain a tracheostomy. And the family might reasonably say, no way. And so we find ourselves in a conflict. We're in a situation where we have differing positions. The ICU team is saying we want a trach, the family is saying, from our perspective, we're probably thinking of the trach as a tool to help us along the road to our ultimate goal of safe vent liberation. That is our interest in this negotiation. But what is the family's interest? Why don't they want a trach? Maybe they think it would be irreversible and would lead to their loved one being ventilator-dependent for the rest of her life. Maybe they've had other loved ones who had a trach and subsequently died and they associate a trach with death. Perhaps the patient herself said that she would never want a trach at some point in the past, or maybe the family sees a trach as a sign the ICU team's giving up on getting her vent liberated. The truth is, it's hard to know if we never ask. In this situation, instead of focusing on our conflicting positions, it can be very helpful to take a step back and think about how we can align our interests. I might start off by stating my interests as clearly and simply as possible. I might say that I want to provide my patients with the best possible care, and I want to maintain a safe, respectful workplace for my team to provide that care. So what does best possible care mean? Well, when possible, I want to help every one of my patients to get better, leave the ICU, and return to the quality of life that they had before they got sick. When that isn't possible, I want to minimize suffering and provide the best possible quality of life that we can. At this point, I can ask the patient's family what their hopes and goals are. Once we have a sense of each other's interests, we can talk about how to align. Maybe this means that we agree on the ultimate goal of safe ventilator liberation, and then we just need to discuss what the best way to achieve that goal would be. Or maybe this means that we recognize that a trach is not aligned with the patient's goals of care and we need to step back and have a broader conversation about what we are trying to accomplish before we can discuss more procedures and interventions. By focusing on interests first instead of positions, we can establish a therapeutic partnership with shared goals instead of having every decision be a source of conflict that makes it more difficult for us to work together going forward. Now I want to shift a bit to talk about our second key concept, trauma-informed care. I'm using trauma here in the mental health context where trauma is defined as an experience of emotional or physical harm that has lasting adverse effects on an individual's functioning or wellbeing. Traumatic events are especially prevalent in low-income communities that have high rates of violence, substance abuse, and loss. And patients and family members who have a history of trauma often have adaptive responses that influence their healthcare interactions. These adaptive responses to trauma include heightened stress reactivity and impaired mood and behavior regulation. This is hypervigilance and defensiveness or anger. In high stress settings, it's common to see impaired cognition and reliance on heuristics. This is where we see families fixate on one position like, he always said he wanted to die peacefully at home or she's a fighter and she'd want us to do everything instead of thinking through the complexity of a difficult situation. Acute stressors can also result in fractured social networks with interpersonal conflict between family members. And it's not uncommon to see maladaptive coping strategies like avoidance or substance abuse. There's an entire published body of literature about trauma-informed care, and there's ongoing research and discussion about how to best apply it to the ICU context. In their excellent paper, Dr. Ashana and her colleagues discussed several principles of trauma-informed care, and I encourage you to read that as well. But for now, to wrap up, I want to discuss a few tactics for managing conflict in the ICU, drawing on lessons from negotiation strategies and trauma-informed care literature. Be proactive about engaging patients and families and use early conversations to discuss and align your interests. Listen to how patients and families interpret the situation. Get a sense of their expectations and fears. Be attentive to signs of trauma and mindful of how that trauma might impact their behavior. Remember that their adaptive responses to trauma are not intended as personal affronts, and often identifying them can help you to address them. Beyond that, explicitly ask about the patients and families' experiences, expectations, and goals. Be frank about your own expectations, but don't take away their hope. It's okay to acknowledge their hopes that you think are unrealistic, and then say something like, and what else are you hoping for if that isn't possible? Give patients and families time and space to cope, process, and grieve. Sometimes a decision needs to be made right away, but often we can introduce a topic and then revisit it in a day or two once they've had a chance to think things over and process. Acknowledge patients and families' struggles and give them a chance to feel heard. You can say, this must be really hard for you. How are you coping? Or, I hear you saying that you're really angry about her illness. Or, I can see that you're really struggling to make a decision. That's normal and understandable. I want you to feel supported as you navigate this process. And finally, when conflicts do arise, and they always do, reframe the conversation about conflicts in terms of shared interests and how we can work together towards a common goal. Thank you for your time. I hope that you found this interesting and informative. These are the articles and books that I mentioned, and they're all strongly recommended for further reading.

conflict management

intensive care unit

negotiation

trauma-informed care

patient and family engagement