To the Editor:
Conflict about treatment decisions is common between families and clinicians in the intensive care unit (ICU) (1) and leads to negative outcomes for patients, families, and clinicians. Interpersonal conflict delays medical decision-making and results in longer ICU stays for patients, causes lasting psychological distress for families, and contributes to moral distress and burnout among clinicians (2–5). Despite the prevalence of interpersonal conflict and its myriad negative effects, little is known about the factors that influence clinician and family perceptions of conflict (1, 5). Therefore, our objective was to describe patient, family, and physician characteristics associated with both physician- and family-reported conflict.
Methods
We conducted a secondary analysis of data from a randomized clinical trial of a decision aid about prolonged (⩾10 d) mechanical ventilation (6). One family member who self-identified as the person most involved in medical decision-making was enrolled per patient. Families randomized to the intervention viewed a decision aid about expected outcomes of prolonged mechanical ventilation, then ICU physicians held unscripted meetings with all families. Families and physicians completed surveys after the meeting, including sociodemographic characteristics and one question about perceived conflict, “I think that there is conflict between the family and the ICU team”, with four possible responses: strongly disagree, disagree, agree, and strongly agree. Trained research coordinators abstracted patient outcomes from the electronic health record after their ICU stay. Family–physician dyads that were missing both responses to the conflict item were excluded from the analysis. To test agreement between families and physicians, responses to the conflict item were regrouped into three categories (strongly disagree, disagree, and any agreement), and an unweighted exact κ statistic was used (7).
Results
Among 275 family participants, the analytic sample comprised 257 (93.5%) family members and 155 physicians. Most family members were White (78.9%) and female (75.1%), and their median age was 52.0 years (interquartile range [IQR], 42.0–61.0) (Table 1). Physicians were predominantly White (76.8%) and male (63.2%), and their median age was 35.0 years (IQR, 31.0–43.0). Many physicians (64.9%) reported equally prioritizing the social–emotional and technological–scientific aspects of patient care, and 76.2% reported engaging families as equal partners in medical decision-making (Table 1).
Table 1.
Demographic and clinical characteristics of families, patients, and physicians, by physician-reported conflict
| No Physician-reported Conflict | Physician-reported Conflict | Total | |
|---|---|---|---|
| N/n | 244 | 13 | 257 |
| Family characteristics* | |||
| Randomized to intervention, % | 50.4 | 46.2 | 50.2 |
| Age, median (IQR) | 52.0 (42.0–61.0) | 57.0 (41.0–65.0) | 52.0 (42.0–61.0) |
| Race, % | |||
| White | 80.2 | 53.8 | 78.9 |
| Black | 12.8 | 46.2 | 14.5 |
| Other or multiple race | 7.0 | 0.0 | 6.6 |
| Female gender, % | 74.2 | 92.3 | 75.1 |
| Relationship to patient, % | |||
| Partner | 47.5 | 38.5 | 47.1 |
| Child | 21.7 | 46.2 | 23.0 |
| Parent | 20.9 | 7.7 | 20.2 |
| Other | 9.8 | 7.7 | 9.7 |
| Lacks social support, % | 3.7 | 23.1 | 4.7 |
| Endorses hope for future, %† | 94.7 | 84.6 | 94.2 |
| Health literacy, median (IQR)‡ | 5.0 (3.0–6.0) | 5.0 (5.0–7.0) | 5.0 (3.0–7.0) |
| HADS score, median (IQR)§ | 14.0 (8.0–21.0) | 12.0 (9.5–21.0) | 14.0 (9.0–12.0) |
| PTSS-10 score, median (IQR)‖ | 23.0 (16.0–33.0) | 26.5 (20.5–35.0) | 24.0 (17.0–34.0) |
| Physician-perceived mistrust of ICU team, % | 2.0 | 53.8 | 4.7 |
| Family–physician discordance about patient’s survival prognosis, median (IQR)¶ | 28.5 (10.0–49.0) | 50.0 (25.0–76.0) | 29.0 (11.0–50.0) |
| Family–physician sex concordance, % | |||
| Female–female | 27.0 | 30.8 | 27.2 |
| Male–male | 15.2 | 0.0 | 14.4 |
| Discordant | 57.8 | 69.2 | 58.4 |
| Family–physician race concordance, % | |||
| White family–White physician | 64.2 | 38.5 | 62.9 |
| Black family–Black physician | 0.4 | 0.0 | 0.4 |
| Other concordant | 0.4 | 0.0 | 0.4 |
| All discordant | 35.0 | 61.5 | 36.3 |
| White family–Black physician | 4.5 | 7.7 | 4.7 |
| Black family–White physician | 11.1 | 23.1 | 11.7 |
| Other discordant | 19.3 | 30.8 | 19.9 |
| Patient characteristics | |||
| Age, median (IQR) | 57.0 (40.0–67.0) | 67.0 (61.0–79.0) | 57.0 (40.0–67.0) |
| APACHE II score at enrollment, median (IQR) | 23.0 (18.0–29.0) | 25.0 (20.0–27.0) | 23.0 (18.0–29.0) |
| Charlson comorbidity score, median (IQR) | 3.0 (1.0–6.0) | 5.0 (4.0–7.0) | 3.0 (1.0–6.0) |
| Days in ICU before randomization, median (IQR) | 12.0 (10.0–15.0) | 12.0 (11.0–14.0) | 12.0 (10.0–15.0) |
| Tracheostomy, % | |||
| None | 38.1 | 53.8 | 38.9 |
| Done before family meeting | 30.3 | 30.8 | 30.4 |
| Done after family meeting | 31.6 | 15.4 | 30.7 |
| In-hospital mortality, % | 29.9 | 61.5 | 31.5 |
| Physician characteristics*,** | |||
| N/n | 142 | 13 | 155 |
| Age, median (IQR) | 35.0 (31.0–42.5) | 39.0 (33.0–46.0) | 35.0 (31.0–43.0) |
| Female sex, % | 36.6 | 38.5 | 36.8 |
| Race, % | |||
| White | 78.2 | 61.5 | 76.8 |
| Black | 3.5 | 7.7 | 3.9 |
| Asian | 11.3 | 23.1 | 12.3 |
| Other or mixed race | 7.0 | 7.7 | 7.1 |
| Self-reported aspects of patient care inclination, % | |||
| Social–emotional | 16.7 | 46.2 | 19.2 |
| Equally social–emotional and technological–scientific | 66.7 | 46.2 | 64.9 |
| Technological–scientific | 16.7 | 7.7 | 15.9 |
| Self-reported decision-making style, % | |||
| Leads decision-making | 10.1 | 7.7 | 9.9 |
| Engages patient or family as equal partner | 76.1 | 76.9 | 76.2 |
| Allows patient or family to make decision | 13.8 | 15.4 | 13.9 |
Definition of abbreviations: APACHE = Acute Physiologic Assessment and Chronic Health Evaluation; HADS = Hospital Anxiety and Depression Scale; ICU = intensive care unit; IQR = Q1 to Q3 interquartile range; PTSS = Posttraumatic Stress Symptoms Checklist.
Missing data counts are as follows: 5 for family age from the group with no physician-reported conflict, 1 for family race from the group with no physician-reported conflict, 2 for social support from the group with no physician-reported conflict, 2 for health literacy from the group with no physician-reported conflict, 19 for HADS from the group with no physician-reported conflict, 1 for HADS from the group with physician-reported conflict, 19 for PTSS from the group with no physician-reported conflict, 1 for PTSS from the group with physician-reported conflict, 1 for race concordance from the group with no physician-reported conflict, 14 for physician age from the group with no physician-reported conflict, 2 for physician age from the group with any physician-reported conflict, 4 for aspects of patient care inclination from the group with no physician-reported conflict, and 4 for decision-making style from the group with no physician-reported conflict.
The question assessing hope was, “I look forward to the future with hope”.
Ranging from 3 to 15 in order of decreasing health literacy.
Ranging from 0 to 42 in order of increasing depression and anxiety.
Ranging from 10 to 70 in order of increasing PTSS.
Ranging from 0 to 100 in order of increasing prognostic discordance.
Of 155 physicians, 60 participated in more than one family meeting (range, 2–7). To avoid repeat measures, if a physician reported conflict with any families, they are included in the physician-reported conflict group.
Physicians reported conflict with 13 (5.1%) families, and 20 (7.8%) families reported conflict with physicians. Physicians and families agreed about the presence of conflict in only 1 case (κ = 0.12, no to very slight agreement; P = 0.007).
Compared with family members with whom physicians did not perceive conflict, those with whom physicians perceived conflict were more likely to be Black (46.2% vs. 12.7%), of a different racial identity than the physician (61.5% vs. 35.0%), female (92.3% vs. 74.2%), the child of the critically ill patient (46.2% vs. 21.7%), lacking social support (23.1% vs. 3.7%), perceived by physicians to be mistrustful of the ICU team (53.8% vs. 2.0%), and disproportionately optimistic about their loved one’s likelihood of survival (50.0 [IQR, 25.0–76.0] versus 28.5 [10.0–49.0], using a measure of family–physician prognostic discordance). Patients with whose families physicians perceived conflict were older (median age, 67.0 vs. 57.0 yr) and more likely to die in the hospital (61.5% vs. 29.9%) than other patients. Physicians who perceived conflict reported prioritizing the social–emotional aspects of care compared with those who did not perceive conflict (46.2% vs. 16.7%) (Table 1). Compared with dyads with no family-reported conflict, family members who reported conflict were more often the partner of the critically ill patient (85.0% vs. 44.1%), and they more commonly perceived conflict with physicians who were female (52.6% vs. 34.6%) or Black (15.8% vs. 2.2%) (Table 2).
Table 2.
Demographic and clinical characteristics of families, patients, and physicians by family-reported conflict
| No Family-reported Conflict | Family-reported Conflict | Total | |
|---|---|---|---|
| N/n | 236 | 20 | 256 |
| Family characteristics* | |||
| Randomized to intervention, % | 51.3 | 40.0 | 50.4 |
| Age, median (IQR) | 52.0 (42.0–61.0) | 55.0 (47.0–65.0) | 52.0 (42.0–61.0) |
| Race, % | |||
| White | 79.1 | 75.0 | 78.8 |
| Black | 13.6 | 25.0 | 14.5 |
| Other or multiple race | 9.0 | 0.0 | 6.7 |
| Female sex, % | 75.8 | 70.0 | 75.4 |
| Relationship to patient, % | |||
| Partner | 44.1 | 85.0 | 47.3 |
| Child | 23.7 | 10.0 | 22.7 |
| Parent | 21.6 | 5.0 | 20.3 |
| Other | 10.6 | 0.0 | 9.8 |
| Lacks social support, % | 5.1 | 0.0 | 4.7 |
| Endorses hope for future, %† | 94.1 | 95.0 | 94.1 |
| Health literacy, median (IQR)‡ | 5.0 (3.0–6.0) | 5.0 (4.0–7.0) | 5.0 (3.0–6.0) |
| HADS score, median (IQR)§ | 14.0 (8.0–21.0) | 17.0 (13.0–24.0) | 14.0 (9.0–21.0) |
| PTSS-10 score, median (IQR)‖ | 23.0 (16.0–33.0) | 31.0 (22.0–38.0) | 24.0 (17.0–34.5) |
| Physician-perceived mistrust of ICU team, % | 5.1 | 0.0 | 4.7 |
| Family–physician discordance about patient’s survival prognosis, median (IQR)¶ | 27.0 (10.0–50.0) | 30.0 (25.0–50.0) | 29.0 (10.5–50.0) |
| Family–physician sex concordance, % | |||
| Female–female | 27.1 | 30.0 | 27.3 |
| Male–male | 14.8 | 10.0 | 14.5 |
| Discordant | 58.1 | 60.0 | 58.2 |
| Family–physician race concordance, % | |||
| White family–White physician | 63.4 | 55.0 | 62.7 |
| Black family–Black physician | 0.4 | 0.0 | 0.4 |
| Other concordant | 0.4 | 0.0 | 0.4 |
| All discordant | 35.7 | 45.0 | 36.5 |
| White family–Black physician | 3.8 | 15.0 | 4.7 |
| Black family–White physician | 11.1 | 20.0 | 11.8 |
| Other discordant | 20.9 | 10.0 | 20.0 |
| Patient characteristics | |||
| Age, median (IQR) | 57.0 (39.0–67.0) | 58.5 (46.0–67.0) | 57.0 (40.0–67.0) |
| APACHE II score at enrollment, median (IQR) | 23.0 (19.0–30.0) | 20.0 (16.5–26.0) | 23.0 (18.0–29.0) |
| Charlson comorbidity score, median (IQR) | 3.0 (1.0–6.0) | 3.5 (2.0–6.0) | 3.0 (1.0–6.0) |
| Days in ICU before randomization, median (IQR) | 12.0 (10.0–15.0) | 13.0 (9.5–15.0) | 12.0 (10.0–15.0) |
| Tracheostomy, % | |||
| None | 39.0 | 35.0 | 38.7 |
| Done before family meeting | 30.9 | 25.0 | 30.5 |
| Done after family meeting | 30.1 | 40.0 | 30.9 |
| In-hospital mortality, % | 31.4 | 30.0 | 31.3 |
| Physician characteristics*,** | |||
| N/n | 136 | 19 | 155 |
| Age, median (IQR) | 35.0 (31.0–43.0) | 34.0 (32.0–36.0) | 35.0 (31.0–43.0) |
| Female sex, % | 34.6 | 52.6 | 36.8 |
| Race, % | |||
| White | 77.2 | 73.7 | 76.8 |
| Black | 2.2 | 15.8 | 3.9 |
| Asian | 12.5 | 10.5 | 12.3 |
| Other or mixed race | 8.1 | 0.0 | 7.1 |
| Self-reported aspects of patient care inclination, % | |||
| Social–emotional | 18.8 | 22.2 | 19.2 |
| Equally social–emotional and technological–scientific | 64.7 | 66.7 | 64.9 |
| Technological–scientific | 16.5 | 11.1 | 15.9 |
| Self-reported decision-making style, % | |||
| Leads decision-making | 9.8 | 11.1 | 9.9 |
| Engages patient or family as equal partner | 74.4 | 88.9 | 76.2 |
| Allows patient or family to make decision | 15.8 | 0.0 | 13.9 |
Definition of abbreviations: APACHE = Acute Physiologic Assessment and Chronic Health Evaluation; HADS = Hospital Anxiety and Depression Scale; ICU = intensive care unit; IQR = Q1 to Q3 interquartile range; PTSS = Posttraumatic Stress Symptoms Checklist.
Missing data counts are as follows: 4 for family age from the group with no family-reported conflict, 1 for family age from the group with family-reported conflict, 1 for family race from the group with no family-reported conflict, 2 for social support from the group with no family-reported conflict, 2 for health literacy from the group with no family-reported conflict, 18 for HADS from the group with no family-reported conflict, 2 for HADS from the group with family-reported conflict, 18 for PTSS from the group with no family-reported conflict, 2 for PTSS from the group with family-reported conflict, 1 for race concordance from the group with no family-reported conflict, 15 for physician age from the group with no family-reported conflict, 1 for physician age from the group with any family-reported conflict, 3 for aspects of patient care inclination from the group with no family-reported conflict, 1 for aspects of patient care inclination from the group with any family-reported conflict, 3 for decision-making style from the group with no family-reported conflict, and 1 for decision-making style from the group with any family-reported conflict. In addition, 1 family member did not complete the conflict item.
The question assessing hope was, “I look forward to the future with hope”.
Ranging from 3 to 15 in order of decreasing health literacy.
Ranging from 0 to 42 in order of increasing depression and anxiety.
Ranging from 10 to 70 in order of increasing PTSS.
Ranging from 0 to 100 in order of increasing prognostic discordance.
Of 155 physicians, 60 participated in more than one family meeting (range, 2–7). To avoid repeat measures, if any families reported conflict with a physician, they are included in the family-reported conflict group.
Discussion
In this hypothesis-generating study, we found that conflict was infrequently reported by families and physicians in the ICU, families and physicians rarely agreed about the presence of conflict, and several clinical and sociodemographic characteristics were more commonly associated with perceived conflict.
In contrast to our findings, between 20% and 50% of family–clinician dyads have reported conflict in prior studies (5, 8, 9). Two differences between our study and the existing literature may explain the lower prevalence of conflict in our study. First, our data were collected for a clinical trial testing a decision aid, which reduced uncertainty about decision-making among families exposed to the intervention, but may also have introduced selection bias (6, 10). Second, unlike in prior studies, participants in our study were asked about perceived conflict immediately after a family meeting, suggesting that family–physician communication may mitigate perceived conflict.
We confirmed a finding by Schuster and colleagues that agreement between families and ICU physicians about conflict is poor (κ = 0.14 in their study) (5). Moreover, we identified several patient and family factors associated with physician-reported conflict, many of which characterize minoritized populations and decision-making under stressful conditions (e.g., high family–physician prognostic discordance) (5, 9, 11). Interestingly, families also more commonly reported conflict with minoritized physicians. Taken together, these results illustrate principles of interpersonal perception theory from social psychology, that different people can have different perceptions of the same situation, and the perceptual filters that shape our understanding of social interactions are influenced by minoritized identity and heightened emotions (12–14). In school settings, this phenomenon has been termed “anger bias”, whereby teachers are more likely to incorrectly perceive negative emotions among Black or female students (15, 16). We hypothesize that similar perceptual biases are present among both physicians and families in their interactions, and these biases are amplified in the high-stress, time-pressed environment of the ICU. This hypothesis requires further study, but if true, it may represent a novel mechanism to explain known inequities in the provision of patient- and family-centered ICU care and potentially uncover inequities in the experiences of minoritized critical care physicians (17–22).
Strengths and Limitations
Our analysis has several strengths, including a multicenter sample and the inclusion of more sociodemographic characteristics than prior studies (5). In addition to possible selection bias, another limitation is the low prevalence of conflict in our data, which precluded the multivariable analyses necessary to understand the relative contribution of the identified factors to perceptions of conflict.
Conclusions
In this hypothesis-generating study, we found that families and physicians rarely agree about the presence of interpersonal conflict, and both families and physicians may more commonly perceive conflict with minoritized individuals.
Footnotes
Supported by the National Institute on Aging (R01AG058915) and the National Heart, Lung, and Blood Institute (R01HL109823).
Author Contributions: All authors fulfilled the following criteria: substantial contributions to the conception, design, analysis, or interpretation of the work; drafting the work or revising it; final approval of the version to be published; and agreement to be accountable for all aspects of the work.
Author disclosures are available with the text of this letter at www.atsjournals.org.
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