Good morning. Today's talk is Conflict Management and Medical Decision Making. My name is Shaila Siddiqui. I'm an assistant professor at Beth Israel Deaconess Medical Center in Boston. The outline for today's talk is definition of types of medical conflicts in the ICU, factors involved in medical decision making, basis of conflicts around therapy and prognosis, trust and communication, recommendations for conflict management and mitigation. The types of medical conflicts that occur in the ICU revolve around the patient at the center, their family, the care team in the ICU, background factors around the patient, and the circumstances of their illness and their presence in the ICU. Conflicts can be around medical decision making, which are therapeutic interventions, the prognosis, end-of-life care, and transition to comfort-focused care. Now, let's take the first aspect of this, factors involved in medical decision making. If you look at the family, the things that affect the family would be background factors, their relationships, especially with regards to the patient, trust with the care team and trust within themselves, communication with the care team, and beliefs. Within the care teams, there could be biases present, their experience, objective data involved in the care of the patient, and guidelines that govern the prognostication and therapeutics of the patient's care. Patient advocacy and professionalism weighs in here. If you look at the patient, prior preferences, goals, and values are important, especially if directives are present, and this would focus on the autonomy of the patient. Circumstances around the patient's care would include ethical principles of non-maleficence and beneficence, and background factors include influences and justice. An important principle to remember here is the principle of proportionality, where the burden of treatment could outweigh the benefit from the treatment, and hence moral distress arises, as well as ethical dilemmas. And for these, we should consider whether the patient would really benefit, and this would be within the goals of care of the patient by the therapy that is offered, or whether the burden of that therapy, for example, dialysis in somebody who is already DNR, DNI, and would not really benefit from the burden of dialysis, which is not a benign procedure, and may cause pain and suffering. Now, the basis of conflicts around therapy and prognostication is around the perspective of families versus the care teams, and this lens and this perspective is often different. So, families are looking at the prognosis from a different lens compared to the care teams, and this can lead to conflict, but it can be mitigated if understood. For example, if you understand and empathize that families see prognosis as hopes, expectations, wishes, faith, and love, facing anxiety, dread, and emotions of a poor prognosis, and this is because facing the loss of a loved one can be the most stressful time in a family's experience. Here, support, empathy, presence, and understanding is required. Care teams see prognosis as a set of objective data and probabilities based on prior evidence-based literature. Patient advocacy involves best interest decision making, looking at the overall chances for a meaningful recovery, and concordance with goals of care, and this requires skill and patience. For example, if you give a family percentages and you say that there is a very small percentage or a very small chance of recovery, this small percentage may mean everything to that family because this is their hope and their emotions are pinned on that hope. However, for the care team, this prognostication may be very, very poor, and this grave prognosis may bias them in terms of moving forward, and they may not feel that there's any point in going on with aggressive management. Now, trust and communication in the ICU around medical decision making is something that is not taught, and it's not something that is very objective, and it's something that is within the nonverbal as well as the verbal communication with the patient if they're awake or with their family members. Treating them as if they were you or your loved one helps because then you understand their point of view, and professionalism requires going the extra mile to empathize and show humaneness. This would include working after hours or even sharing the grief with the patient's family. However, this can impinge upon distress and burnout for the care team, and the balance is very, very important. Active listening and presence is very important, doesn't take much time, but it is very important that the communication is also nonverbal, and just being present with the family in their most difficult times with a point of view of actually sharing their grief will go a long way in building that trust, in giving comfort to that family. Identifying and de-escalating conflict before it becomes intractable is a preferred approach. The recommendations around conflict management are techniques that all ICU clinicians may use to identify and manage conflict. Entrenched conflict appears to benefit from bioethics mediation as well, an approach that uses a neutral, unaligned mediator to guide parties to a mutually acceptable resolution. Tools of self-regulation, negotiation, compromise, trust-building, understanding perspective, and respect for opinions and flexibility are important tools to have. One way of building these tools is to develop emotional intelligence, and this can be taught, it can be learned. It develops from self-awareness, empathy, motivation to know more and to share more, self-regulation of one's own feelings and emotions, and social skills in dealing with colleagues, dealing with families, dealing with patients. Emotional intelligence includes self-awareness, which recognizes biases and emotions, which can trigger certain behaviors, empathy to build feelings of compassion and be honest in feeling empathy, motivation, feel fulfillment from touching a life and making a difference, also known as ikigai in Japanese, where you derive fulfillment from what you do, and self-regulation, controlling urges, emotions, compelling reactions and attitudes, to build control and social skills, friendships with colleagues, camaraderie, trust and bond with family and patient with mutual respect. In conclusion, there are many causes of team, patient, family, or inter-team conflicts. We are all human and have attitudes and behaviors that may lead to conflicts. Perspective, understanding, and emotional regulation is the key. Organizational support is necessary. Debrief and ethical learning is important. And leadership that sustains an ethical climate is required for mitigating conflicts. Thank you.

conflict management

medical decision making

ICU

trust

communication