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* Harvard School of Public Health
Boston Children’s Hospital
Brigham and Women’s Hospital, Boston, Massachusetts
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONREFERENCES |
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Setting. A tertiary care, university-affiliated PICU in Boston.
Participants. All patients admitted over an 11-month period whose stay exceeded 8 days (the 85th percentile length of stay for the PICU under study), and intensive care physicians and nurses who were responsible for their care.
Methods. We prospectively identified conflicts by interviewing the treating physicians and nurses at 2 stages during the patients’ PICU stay. All conflicts detected were classified by type (team-family, intrateam, or intrafamily) and source. Using a case-control design, we then identified predictors of conflict through bivariate and multivariate analyses.
Results. We enrolled 110 patients based on the length-of-stay criterion. Clinicians identified 55 conflicts involving 51 patients in this group. Hence, nearly one half of all patients followed had a conflict associated with their care. Thirty-three of the conflicts (60%) were team-family, 21 (38%) were intrateam, and the remaining 1 was intrafamily. The most commonly cited sources of team-family conflict were poor communication (48%), unavailability of parents (39%), and disagreements over the care plan (39%). Medicaid insurance status was independently associated with the occurrence of conflict generally (odds ratio = 4.97) and team-family conflict specifically (odds ratio = 7.83).
Conclusions. Efforts to reduce and manage conflicts that arise in the care of critically ill children should be sensitive to the distinctive features of these conflicts. Knowledge of risk factors for conflict may also help to target such interventions at the patients and families who need them most.
Key Words: physician-patient relations • conflict (psychology) • intensive care • withholding treatment • communication barriers
Abbreviations: ICU, intensive care unit • PICU, pediatric intensive care unit • CICI, Care Improvement for the Critically Ill • CI, confidence interval
Few areas of medicine are as emotionally charged for the individuals involved as the care of critically ill children. Families face important treatment decisions at a time of grief, stress, and fatigue.1–3 Clinicians must execute highly demanding clinical tasks, provide constant prognostic updates, educate family members, assist them in coping, and also help them to make difficult decisions about the care of loved ones.4–7 This volatile environment is conducive to conflict.8
Previous investigations of conflict in the intensive care setting have had a particular focus: disagreements between clinicians and families about end-of-life decision-making for adult patients.9–15 This frame of reference is limited in 3 significant ways. First, although decisions about life-sustaining treatments are clearly an important trigger for disputes in the intensive care unit (ICU), disagreements arise in a range of other circumstances. Second, no previous studies have investigated conflicts arising in the care of children, and important differences with adults may exist. For example, because there is often consensus about the need for aggressive treatment in the pediatric intensive care unit (PICU),16,17 sources of conflict unrelated to limitations of care may figure more prominently in this setting than in adult ICUs. Third, disputes in the ICU are not confined to the clinician-family relationship ("team-family"); they may also occur among clinicians ("intrateam") and within families ("intrafamily"). Conflict along each of these axes threatens quality of care.
As part of a quality improvement initiative in the medical and surgical ICUs of the Harvard medical institutions, we prospectively tracked conflicts arising in the PICU at Children’s Hospital in Boston over an 11-month period. Rather than screen patients for analysis based on whether their care involved consideration of care limitations, as previous studies of critically ill adults have done, we focused on all clinician-reported conflicts associated with the care of patients who had prolonged stays in the unit during the study period. Our goal was to measure the frequency of different types of conflicts and clinicians’ perceptions of the sources of those conflicts. In addition, we sought to identify predictors of conflict by using patients whose care did not involve disputes as controls.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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This screening criterion was chosen based on the consensus reached by a consortium of community representatives and critical care experts in a series of meetings at Harvard Medical School in 1999.18 The experts included the medical director and nurse manager from each of the 8 intensive care units (neonatal, pediatric, adult medical and surgical) affiliated with Harvard Medical School. The consortium determined that long-stay patients are especially prone to serious conflicts given their acuity, the complicated nature of their illness, and the greater "exposure" that they, their families, and their care givers have to potential disputation. The Institutional Review Board at Children’s Hospital approved the study protocol.
Identification of Conflicts and Controls
We prospectively identified conflicts arising in the care of PICU patients through structured interviews conducted in person with 1 physician and 1 nurse involved in the patients’ care. Specifically, the interviewees were the pediatric intensivist who was the attending and the nurse with primary responsibility for the study patient on the day of the interview. The interviews occurred at 2 stages in the PICU stays: 1) immediately following the patient’s enrollment in the study (ie, on or close to day 9); and 2) 7 days after enrollment, at discharge from the PICU, or at death, whichever came first. Interviewers, who were trained in the use of the study instrument, asked the clinicians whether a conflict had occurred, and if so, to describe its type and major source(s).
Draft questions pertaining to conflicts were formulated during the consortium meetings; we refined these questions and tested their face validity in focus groups of community representatives and experts during a 2-day workshop before the research began. For purposes of our analyses, PICU patients with conflicts consisted of those identified by nurses and/or physicians in either of the clinician interviews as having had a conflict arise in their care. Controls were patients who had no conflicts linked to their care by either clinician in either interview.
Definition, Verification, and Classification of Conflicts
The study definition of "conflict" was a dispute, disagreement, or difference of opinion related to the management of the patient involving more than one individual and requiring some decision or action. In formulating this definition, we drew on the literature of dispute resolution in health care.19 Interviewers reminded the clinicians that conflicts may occur both between and among families and clinicians in the PICU; interviewers also noted that conflicts may occur in a range of circumstances, including disagreements over the major goals of therapy, misunderstandings about expected outcomes, and decisional paralysis.
To ensure that affirmative responses from clinicians referred to events that actually met our study definition of conflict, 2 investigators independently reviewed the written interview record to verify each conflict. In cases in which the event described was judged not to meet the study definition of conflict (eg, decisional paralysis without an identifiable dispute), and the relevant patient had no other verified conflict associated with his or her care, the patient was added to the controls. Once the group of conflicts was finalized, 2 coders independently classified each conflict by type (team-family, intrateam, intrafamily), allowing a conflict to be classified as more than 1 type if appropriate.
Next, we classified all conflicts into source categories using an iterative process.20 First, we reviewed the literature on disputes in the ICU and health care generally to formulate a draft set of categories. Second, we drew a random sample of 15 conflicts from our group and tested their fit within the draft categories, making modifications as necessary. The final codebook contained 6 primary sources of team-family disputes (disagreements about the care plan, poor communication, inability of a parent/guardian to make decisions, unavailability of a parent/guardian, coping problems, other), 5 sources of intrateam disputes (disagreements about the care plan, poor communication, lack of leadership, lack of coordination, other) and 3 sources of intrafamily disputes (disagreements about the care plan, communication problems, other). Third, 2 coders independently classified each conflict into 1 or more of these primary source categories. Disagreements in this and the other stages of the verification/classification process were discussed and resolved by consensus using all available information from the transcript.
Patient Data
We obtained additional data on all patients (cases and controls) from medical charts and hospital administrative databases, including demographic information (age, sex, marital status, religion, insurance status) and measures of patient acuity. The acuity measures used were the Pediatric Risk of Mortality score21 and the Therapeutic Intervention Scoring System,22,23 a measure of the amount of resources used. Research nurses also used a chart abstraction tool adapted from the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment24 to collect data on whether or not clinicians had a documented discussion with a patient’s family about withholding or withdrawing life-sustaining treatments (including decisions to forgo resuscitation, ventilator, vasopressors, dialysis, blood transfusion, tube feedings/total parenteral nutrition, antibiotics, and major surgery).
Statistical Analysis
We used the SAS and STATA statistical packages to generate descriptive statistics on the types and sources of conflicts, as well as the characteristics of patients whose care did and did not involve conflicts. For further analysis of patient characteristics associated with conflict, we used bivariate and multivariate logistic regression models to compare controls with 2 types of cases: 1) patients with any type of conflict; and 2) patients with team-family conflicts specifically. In the first model, controls consisted of all patients that did not have any conflict; in the second model, controls consisted of all patients that did not have a team-family conflict. The dependent variable in these models was whether or not a conflict had occurred. The independent variables were patient gender, race (white, non-white), age (<1 year or older), insurance status (private, Medicaid, other), religion (Catholic, Protestant, Jewish, other), whether or not a discussion about limiting care had occurred, acuity (Pediatric Risk of Mortality and Therapeutic Intervention Scoring System scores), and length of stay in the PICU.
We examined the extent of agreement between physicians and nurses about the occurrence of conflicts by analyzing "paired interviews"—that is, instances in which both physician and nurse interviews were completed in the specific interview window (enrollment or 7 days/discharge/death) at which the conflict was identified. Finally, we calculated 
statistics to measure the reliability of the processes we used to verify conflicts and classify them by type and source.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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For 2 patients, neither physician nor nurse interviews were completed in either stage, reducing our effective sample size to 108 patients. For the vast majority of these patients, we completed all clinician interviews (57%) or 3 of the 4 (28%) interviews; 14 patients (13%) had 2 interviews completed and 2 patients (2%) had only 1. Uncompleted interviews were attributable to clinicians’ refusal or their unavailability.
Typology
Table 1 shows that 33 conflicts (60%) were team-family disputes, 21 (38%) were intrateam conflicts, and the remaining conflict occurred among family members. More than half of all intrateam conflicts, or 20% of conflicts overall, involved disputes between members of the PICU team and surgical specialists.
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Among intrateam conflicts, poor communication (38%) and disagreements over the care plan (33%) were the most common sources, with the latter linked to life-sustaining treatment issues in 1 case only.
Predictors of Conflict
Bivariate comparisons of PICU patients who had conflicts identified in the course of their care with those who did not revealed a number of significant differences (Table 3). Patients with conflicts were significantly more likely to be from the nonwhite race category (45% vs 25%; P = .02) and have Medicaid insurance coverage (43% vs 14%; P = .001), whereas they were significantly less likely to have private health insurance (55% vs 81%; P = .004), and be Catholic (24% vs 47%; P = .009). More focused bivariate comparisons, comparing only patients who had team-family conflicts with controls, showed the same characteristics associated with increased (non-white race, Medicaid insurance) and decreased (private insurance, Catholic religion) risk of conflict. The magnitude and significance level for each of these differences were similar to those observed in the comparisons of all conflicts to controls.
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In contrast, only 1 of the 16 intrateam conflicts identified in paired interviews was cited by both nurses and physicians; the remainder were reported by nurses4 and physicians11 alone. At least part of the explanation for these discrepancies appears to flow from the nature of the conflicts. The descriptions of conflict in the solo reports by physicians suggested that most occurred among physicians, whereas 3 of the 4 solo reports by nurses involved disputes with physicians over physician leadership and availability, which the physicians themselves may have perceived as not constituting a substantive conflict.
Reliability of Coding
Investigators’ independent reviews of the interview transcripts showed excellent interrater reliability for the presence of conflict ( = 0.93; 95% confidence interval [CI]: 0.86–1.00). There was also a high level of agreement between coders about the typology of conflicts ( = 0.83; 95% CI: 0.69–0.97). The reliability of the classification of conflicts into sources was excellent among team-family conflicts ( = 0.94; 95% CI: 0.88–1.00) and fairly good among intrateam conflicts ( = 0.73; 95% CI: 0.52–0.94). Three of the 5 disagreements between investigators about the sources of intrateam conflicts were resolved by creating a new category that recognized the unavailability of clinician colleagues as a source.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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To the best of our knowledge, no previous studies have addressed the epidemiology of conflict surrounding the care of critically ill children. Moreover, studies of conflicts in the adult ICU have tended to focus on patients facing end-of-life decisions.11–13 Despite their contrasting frames of reference, our PICU findings bear 1 notable similarity to their adult forebears: breakdowns in communication are at or near the top of the list of key factors leading to both team-family and intrateam conflict.
But several important differences are also apparent from our findings. First, PICU care appears to be especially prone to conflict. Although several leading adult studies have found rates of conflict in the same range or even higher than those we observed,11,12 such comparisons are misleading given "enrichment" of those samples with cases known to involve sensitive decisions about life-sustaining treatments. The most comparable data—our own CICI analysis of conflict among adults with prolonged ICU stay25—suggest that rates of both team-family and intrateam conflict in the PICU are 
50% higher.
Second, divergent preferences over life-sustaining treatment appear to be a much less prominent source of conflict in pediatric than adult critical care. Clinicians in CICI linked conflict to disagreements over limitations of care in approximately 1 in 10 PICU patients, compared with one third of adults with prolonged stays in surgical intensive care units.25 This discrepancy in no way diminishes the complexity and profound nature of many of the disputes around withholding or withdrawing care that do occur in the PICU.4 But it does suggest that extrapolation of the results of research in adult settings to the pediatric realm will miss an important set of flashpoints. Third, the unavailability of decision makers appears to be a much more common irritant in PICU care, probably because of the dependence clinicians have on parental input in day-to-day decisions about the course of care.
A range of strategies have been proposed for mitigating the harmful impacts of disputes in the ICU, including ethics consultations,26,27 mediation,28,29 innovative communication strategies,9,30 and other approaches.31 In the pediatric context, these efforts should be sensitive to the distinctive aspects of PICU conflict. In addition, targeting efforts to reduce and manage conflict at the patients whose care poses relatively high risk of this event should enhance the effectiveness of these interventions. Our study provides new information in this regard.
We found that the odds of conflict among Medicaid-insured patients were 5 to 8 times higher than they were among privately insured patients. What accounts for this dramatic discrepancy? The relationship between socioeconomic status and interpersonal aspects of health care has proven difficult to disentangle because of the confounding role played by various other factors.32–35 We controlled for several of the most troubling of those confounding factors—namely access to care, race, and acuity—and Medicaid insurance remained strongly associated with conflict in our analysis. Nonetheless, 3 factors correlated with this form of insurance, rather than Medicaid or low income per se, present the most likely explanations for the increased risk of conflict we observed.
First, the importance of poor communication as a source of team-family conflict suggests that lower levels of education may play a role. Second, parental unavailability may be linked to difficulties that poorer families face in visiting the hospital regularly. Previous research has documented that families of seriously ill patients experience severe financial burdens,36 which may cause or exacerbate availability problems. Third, there is some evidence of a link between lower socioeconomic status and reduced levels of both trust in providers and satisfaction with medical care.32,35
It is important to stress that identification of Medicaid insurance as a risk factor does not locate responsibility for conflict with a particular party. For example, limited education among families with Medicaid insurance may increase the probability of team-family disputes if it limits the families’ ability to comprehend prognostic information. On the other hand, clinicians’ skepticism, frustration, or relatively poor ability to communicate information to these families may be every bit as important a contributing factor. In any case, Medicaid insurance stands as a strong marker of conflict in the population we studied, and knowledge of this connection could be deployed toward maximizing the timeliness and effectiveness of quality improvement interventions.
Our study has several limitations. First, further research is needed to determine if Medicaid insurance is associated with conflict in other PICUs and in patients with shorter lengths of stay. Second, clinician reports reveal a limited perspective; family reports may differ with respect to both the frequency and type of conflicts. Third, not all clinician interviews were completed for all patients, although to the extent that conflicts were missed this way, it would tend to understate the frequency of conflicts and bias differences between cases and controls to the null in our comparative analyses.
Finally, our study is limited by the fact that we did not directly measure conflicts’ severity or their precise impact on quality of care. Some conflicts may not have had an adverse impact; on the contrary, they may even be positive events—for example, unavoidable episodes in the maturation of a family’s decision-making, precursors to a breakthrough in comprehension and coping, or, in the case of intrateam conflicts, a constructive by-product of the close attention given by multidisciplinary team. More finely tuned research is needed to delineate constructive conflicts in the PICU from destructive ones.
However, even without such additional insights, information about the general epidemiology of conflicts that arise in the care of critically ill children is valuable if it is used to facilitate interventions such as ethics consultations and family meetings. These flexible measures promise improvements in the quality of care not simply by quelling disagreements in the PICU. Rather, when they are timely, well designed, and well executed, they arm caregivers with an opportunity both to mitigate the adverse consequences of conflicts and amplify the productive ones.
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ACKNOWLEDGMENTS |
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We thank Benjamin Galper for research assistance.
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FOOTNOTES |
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Reprint requests to (D.M.S.) Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115. E-mail: studdert{at}hsph.harvard.edu
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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This article has been cited by other articles:
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  N. Kassam-Adams Introduction to the Special Issue: Posttraumatic Stress Related to Pediatric Illness and Injury J. Pediatr. Psychol., May 1, 2006; 31(4): 337 - 342. [Full Text] [PDF]
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A. E. Kazak, N. Kassam-Adams, S. Schneider, N. Zelikovsky, M. A. Alderfer, and M. Rourke An Integrative Model of Pediatric Medical Traumatic Stress J. Pediatr. Psychol., May 1, 2006; 31(4): 343 - 355. [Abstract] [Full Text] [PDF]
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 A. L. Back and R. M. Arnold Dealing With Conflict in Caring for the Seriously Ill: "It Was Just Out of the Question" JAMA, March 16, 2005; 293(11): 1374 - 1381. [Abstract] [Full Text] [PDF]
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