I'm Preeti John. My background is in surgery, but I also consider myself an intensivist, a palliative medicine physician. And I have to tell you that in every setting that I've worked in, the OR, the trauma bay, the ICU, tele-ICU, and a hospice setting in the VA, I've experienced different types of conflict. And as a trainee, I wasn't always sure about how to deal with them. And I hope that by the end of this session, you'll learn about some of the ways and strategies to deal with conflict. I'm going to zip through the initial slides. You've heard from the subject matter expert about the causes of conflict. Basically, it's defined by human elements and emotions. There are different phases of conflict, different sources of conflict. And I'm not going to address intra-team conflict. There are several resources that you can use for that. I'm going to focus on concepts that I think are important for you to take away when you think about how best to address conflict in a clinical setting. These are four terms that I'll expand on. Amygdala hijack. It's an actual biologic phenomenon that was first described by a psychologist. And it results in sudden illogical overreaction to situations. The prefrontal cortex does not have the ability to process rational thought. And you get these stress response activated reactions. And in these situations, it's important to know that rational thought is not possible. So it's important for us as clinicians to realize that there is a biologic basis for intense reactions that you may see. Moral aporia. This is a state of perplexity or ambiguity that exists around situations. It's important for us as clinicians to know that what we would want or what we would advise may not be the only ethically justifiable or morally justifiable outcome. So it's important for us to think beyond black and white ethical versus unethical options. And sometimes what the patients or families request may not be justifiable in our view. But that doesn't mean that it's not morally justifiable. Important for us to know about interests and positions. Any negotiation involves knowing what underlying interests are. What we hear from family members are positions, what they want. It's the externally articulated preferences. But it's important to explore where those preferences come from. Any interests have to be explored in order for us to be able to put ourselves in their shoes and kind of see things from their perspective. In any conflict, there are two things at stake. Results and relationships. And compromise should kind of figure out what you're willing to give up in those situations. Conflict management strategies are listed here. Avoidance is actually advisable when you're dealing with the amygdala response. When people are heated and irrational and emotional. You saw the two previous speakers who talked about emotions being a key factor in conflict. Conflict resolution can be achieved by communication. And a key part of this is listening. And listening is a skill that can be learned. There are different types of listening. They're listed here. Analytical, relational, critical, task-focused. We don't stress this enough. Different conflict management styles have been described in the clinical setting. Task-focused communication and relationship-building communication. These authors showed that palliative medicine physicians focus more on relationship-building communication. And I suspect that ethics consultants do as well in comparison with intensivists and maybe proceduralists who focus more on task-focused communication. This is a paper that describes relationship-building communication. Active listening, acknowledging feelings and emotions and different perspectives are key components. Addressing conflict often cannot be done without involving third parties. Whether it's consultation or calling in a conflict management team. Ethics consultation and palliative medicine consultation are usually available in healthcare facilities. They differ from conflict management teams because they focus on relationship-building with the patient and the surrogate and the families. Conflict management teams are different. They may not be medically trained and they focus on the actual conflict and resolution of the conflict and they try and stay impartial. Bioethics mediation is the use of negotiation techniques by trained mediators and neutral third parties can be used. Clinicians can get this training but of course it's important to have institutional support because this takes resources in terms of finances and time. This is an actual example from a tertiary care center. Patient sustains a cardiac arrest, is resuscitated once, arrests again. The intensivist decides that it's not gonna be appropriate to resuscitate again, communicates that with a family member and the family member approaches the physician in a threatening manner, has that amygdala response and at that time it's best for the intensivist to step away. This particular tertiary care center had a behavioral emergency response team or a conflict management team and they also had panic buttons on their desks at nursing stations which I realized that not all facilities have. Spiritual support is something that we don't utilize often enough. I didn't have a good understanding of this when I was training but it's different from religious people who are available for families. Spiritual support comes in terms of spiritual advisors or chaplains and they don't focus on religion. And of course intractable conflict you may have experience with after exhausting all available resources, we sometimes have legal recourse as our only option. The last few slides are gonna be about end of life conflict and how to deal with them and for anyone who has not read this policy statement, please do, it's really worth reading. One of the authors is sitting right here. It really talks in detail about how to respond to requests. It gives you step-by-step suggestions and Dr. White had mentioned how important it is to be clear about our thinking and make sure that families understand what our thoughts are and why certain decisions are being made because it's often fuzzy in the stress that ensues when your family member is sick and there's a lot of emotion and stress involved. They talk about responding to futile treatments, make sure we are empathetic, provide emotional support and we can of course enlist the support of spiritual care providers as I just mentioned for that emotional support. These are just the steps that are listed and it involves second medical opinions in some cases, getting consultations by clinicians that I mentioned earlier and basically goes through the steps of what can be done when you are dealing with situations that are difficult. It also talks about the difference between potentially inappropriate treatments and futile treatments. Intensivists often throw around the word futility and it's important for us to kind of differentiate that so that our students and our residents can tease out the differences. There are different types of futility and this paper talks about kind of limiting the use of that word to physiologic futility. So potentially inappropriate treatments is more appropriate for a treatment that might accomplish the desired physiologic effect and might produce benefits that may be controversial. And the impact of the words we use as Dr. White mentioned is really, really cannot be stressed enough. This is a paper that is so worth reading. One of the authors is sitting right here. We often ask about what the patient or the surrogate would want in certain situations to promote shared decision making and elicit information from surrogates about patient preferences. But want may not be the best choice of words. Do you want us to do everything we can? It just encourages an affirmative answer. No one who loves their family member is gonna say no. What would she want if her heart stops? The word focuses on medical treatments and can shut down further discussion. Instead, try other words like what would she think, what would she feel, what would she say about this? You may have encountered situations where you talk to a family about the very, very small chance of their loved one recovering and the family says, I believe in miracles. We heard about miracles from the previous two speakers. This article is great. It describes how you may approach such situations. Empathetic imagining involves setting aside your own concept of what exists and what is right and attempting to understand the patient as a person. Spiritual care professionals are wonderful resources that we should utilize more in the ICU setting. They're different from religious authorities. And of course, family meetings, listening, time-limited trials and institutional process-based mechanisms are important. Institutional support is key and it's important for us to be aware of protocols that exist. This is the last slide. Time-limited trials in critically ill patients. They involve detailed discussions of patient preferences and decisions between clinicians and surrogates to use certain medical therapies for defined periods of time. It's been shown to decrease the intensity and duration of non-beneficial ICU treatments in this study. And I've put all the references there so that you have them easily available. And that concludes this section of the talk. I wanna acknowledge my colleagues and thank you for listening.

Dr. Preeti John

conflict resolution

amygdala hijack

moral aporia

end-of-life conflicts