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Conflict Management in the ICU
11 Plays3 years ago
In this episode of the podcast, we will discuss the management of conflict in the intensive care unit (ICU). Our guest is Dr. Joshua Kayser. Dr. Kayser is Section Chief for Medical Critical Care Medicine and Medical ICU Director at the VA Medical Center in Philadelphia. He is also Professor of Clinical Medicine and Professor of Medical Ethics and Healthy Policy at the University of Pennsylvania.
Additional Resources:
Conflict Management in the ICU. JB Kayser and LJ Kaplan: https://pubmed.ncbi.nlm.nih.gov/32618689/
How doctors manage conflicts with families of critically ill patients during conversations about end-of-life decisions in neonatal, pediatric, and adult intensive care. AS Spijkers et al.: https://link.springer.com/article/10.1007/s00134-022-06771-5
Center to Advance Palliative Care Website – with great resources: https://www.capc.org/
Vital Talk website. A great resource for developing communication skills in healthcare: https://www.vitaltalk.org/
Books Mentioned in this Episode:
In Shock. By Rana Awdish: https://amzn.to/3UzJtTg
Recommended
Transcript
Introduction to Critical Matters Podcast
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
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Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
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To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:26
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And now your host, Dr. Sergio Zanotti.
What are the effects of conflict in the ICU?
00:00:33
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The ICU is a stressful and highly charged environment.
00:00:35
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The potential for conflict to emerge is always present.
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Conflict has negative effects on patients, families, and the healthcare team.
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In today's episode of the podcast, we will discuss conflict management in the ICU.
00:00:47
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Our guest is Dr. Joshua Kaiser.
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Dr. Kaiser is Section Chief for Medical Critical Care Medicine and Medical ICU Director at the VA Medical Center in Philadelphia.
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He's also Professor of Clinical Medicine and Professor of Medical Ethics and Health Policy at the University of Pennsylvania.
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Dr. Kaiser is a recognized clinician, educator, and researcher.
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His areas of interest include end-of-life, medical ethics, and communication.
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He is the author of an excellent review article titled Conflict Imagined in the ICU and published in Critical Care Medicine recently.
00:01:19
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It is a privilege and honor to have him on the podcast today.
00:01:22
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Josh, welcome to Critical Matters.
Types and impacts of ICU conflict
00:01:25
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Thanks for having me.
00:01:27
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So I think that as an introduction, maybe you could just give us a little bit of a general overview of how you see conflict in the ICU.
00:01:37
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Sure.
00:01:39
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I think that conflict in the ICU is something that is relatively uncommon, I think, but certainly has a disproportionate burden on health care team members.
00:01:56
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We tend to remember those difficult moments much more often than we remember the good ones.
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the good saves, the patients who get better, the families that are appreciative of the care that we provide.
00:02:07
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These are all really important things that help keep us going, that help sustain us, help maintain resilience.
00:02:15
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But I think that those moments when there is conflict, discord, and discomfort,
00:02:23
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play a disproportionate role in how we perceive our environment and our profession, our careers, our satisfaction, and certainly lead to burnout for those of us in the ICU.
00:02:38
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And obviously, the last couple of years have been pretty notable in particular.
How do different values lead to conflict?
00:02:44
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And the other thing I would say about conflict is that I think that we oftentimes think about conflict as being where someone is doing something wrong, someone is making bad decisions, someone is behaving badly, when the reality is it's oftentimes really just about differences of opinions, differences of perspective, of values that drive a lot of the conflict that we see.
00:03:11
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In terms of etiology or origins of conflict, what do you think is the most common
00:03:20
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Yeah, I mean, I think that, you know, the first thing we have to do is separate types of conflict.
00:03:25
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And I think that there is conflict between healthcare team and patient or family, which is what we oftentimes think about.
00:03:36
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But then there's also conflict between healthcare team members.
00:03:40
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And I think we are quick to forget sometimes that
00:03:48
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that much of the conflict we experience may be because of differences in opinions around healthcare team members that we have to continue to work with on a daily basis, and that can cause a lot of discomfort and frustration.
00:04:04
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I think that, you know, when we think about the conflict as we often see it
00:04:12
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as the most common cause of conflict.
00:04:15
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The thing that pops into our head first is certainly families and patients.
00:04:20
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And I think that really comes from, uh,
00:04:25
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different value sets, different cultural beliefs or subcultural beliefs, and perspectives about what patients and by extension their families want for their loved ones who are either critically or terminally ill and how that may deviate from what we perceive we would want as healthcare team members if we were in that position.
00:04:48
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Absolutely.
00:04:49
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And I think another source of conflict that you have written about as well is, and we tend to forget, is that there might be conflict among the patient's family.
00:04:59
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And we often get pulled into that and with some of the tools that you'll describe today, may be able to help.
00:05:07
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Yeah, I think that's absolutely right.
00:05:08
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That's a great point, and I appreciate you bringing it up.
Challenges of intra-family conflicts
00:05:11
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Certainly, intra-family conflict where you have individuals, stakeholders among the family unit who may have a difference of opinion or perspective or something else underlying their particular view for what they see as sort of, and I put this in quotes, what's right for the patient.
00:05:32
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can certainly drive conflict and can be very difficult for healthcare team members to navigate because the moment you do it, the moment you attempt to address that conflict, if you're not careful, it can drive a wedge in a relationship and it can pit you against certain family members who see you as taking sides.
00:05:55
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And so you have to be very thoughtful about how you approach that.
00:05:59
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I believe, Josh, that a lot of times we use terms, but we're not as careful and really differentiating what different terms might mean.
00:06:08
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And in all topics, especially in conflict, I think that differentiating between what some people might think are similar, but are actually quite different and have an implication in how we deal with conflict is
00:06:20
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is worthwhile exploring.
00:06:22
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So I wanted to give you a couple of pairs of juxtaposed terms, but I wanted you to differentiate one versus the other.
00:06:29
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So would that be okay?
00:06:31
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Sure, yeah.
00:06:32
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So the first pair is disagreement versus conflict.
00:06:36
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Mm-hmm.
00:06:39
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Yeah, I mean, I think that disagreement is just what the word really indicates, which is when there are two or more parties who differ in their perspective or their opinion about the best choice for a patient or a best choice by the patient.
00:07:01
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And disagreements happen all the time.
00:07:06
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I think that the difference, I think that the key difference between disagreement and conflict is when the difference in opinion begins to cause a breakdown in communication and a breakdown in the relationships.
00:07:23
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I certainly have explicitly said to families when there's a difference of opinion that it's, you know, I'll say something like, it sounds like we disagree on what we think is the best choice for mom or dad, let's say.
00:07:39
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And that's okay.
00:07:40
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We're allowed to disagree.
00:07:41
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It doesn't mean that we don't care about them.
00:07:43
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It doesn't mean that we don't want to try to do the best that we can for them.
00:07:47
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It just means we have a difference of opinion.
00:07:49
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And I think that disagreements, it's easy to align yourself with families when there's a disagreement because you can appreciate their perspective.
00:07:58
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I think that when you get into conflict, you get so entrenched in your own positions and your own thoughts that it becomes very difficult for you to see the other perspective, to see how the other person is perceiving things or viewing things and why their particular view might deviate from yours.
00:08:16
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And that when you then...
00:08:19
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have breakdowns in communication, it perpetuates the conflict in a way that ultimately prevents you from moving forward.
00:08:27
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And I think that's probably the key difference between a disagreement versus a conflict.
00:08:30
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Excellent.
00:08:32
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Positions versus interests.
Understanding positions versus interests in conflict
00:08:36
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Yeah, I mean, this is a really interesting one, and this is not something that I developed.
00:08:40
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This is something that comes from the business world, and one of my mentors in medical ethics sort of took it from the business world where there's –
00:08:52
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arbitration and and created sort of a a medical version of it and so I think that the way that I have described it before and the way she describes it is if you imagine a tree where you've got the tree trunk and the branches and the leaves and then below the ground you've got the roots of the tree and the positions are what you can see
00:09:13
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It's the trunk, it's the branches, it's the leaves.
00:09:16
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So it's, it's really can be defined as what I want.
00:09:18
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And so a great example might be something like, um, a binary decision in the ICU, like, uh, renal replacement therapy, CPR intubation.
00:09:29
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Um, the position would be you either want it or you don't want it.
00:09:32
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So it's very binary.
00:09:34
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Um, and you can imagine a family saying, I want dialysis for my spouse.
00:09:40
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Um, um,
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and the healthcare team feeling like dialysis is not a good choice and that there may be compelling medical reasons not to offer dialysis.
00:09:50
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And our position is we don't want to give dialysis.
00:09:53
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And those are binary positions.
00:09:55
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And there's really not a lot of space for dialogue and a lot of space for compromise.
00:10:00
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You either want it or you don't.
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The interest would be what's below the surface, the roots of the tree.
00:10:04
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It's why I want it.
00:10:07
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And so, you know, the family may have...
00:10:10
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a very unique reason why they want renal replacement therapy.
00:10:16
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Maybe they have a prior healthcare experience with dialysis where things went well and they're drawing on those prior experiences.
00:10:23
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Maybe they feel like the healthcare team is quote unquote giving up on their loved one and they feel that offering dialysis, doing dialysis would be a demonstration of
00:10:32
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the healthcare team aligning with the family and trying to do everything possible to reverse critical illness.
00:10:43
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And conversely, you know, we may have our own experiences in healthcare as providers, as nurses, as team members, where...
00:10:53
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You know, doing dialysis, there's a compelling reason that doing dialysis doesn't make sense.
00:10:57
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And so when you really dig down under the surface and you look at the interest of why someone wants something, you can then begin to find nuance and you can find room for compromise and ways to partner with each other so that everyone feels like they're not necessarily getting what they want, but they're being heard.
00:11:15
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And I think that's the most important thing is that people feel like they're heard.
00:11:20
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And I think that this is worth emphasizing that this distinction is important as we try to de-escalate or resolve conflict because we are more likely to find common ground in interest than maybe in positions when there's conflict.
00:11:35
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And it's definitely a direction that we want to always take at the bedside or outside of the bedside in resolving or de-escalating conflict.
De-escalating conflicts by questioning interests
00:11:44
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Yeah, I mean, I think that's exactly right.
00:11:46
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And I would say that the most important tool an intensivist can have or a health care team member in critical care can have is curiosity.
00:11:56
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I think curiosity and compassion are probably very closely aligned.
00:12:02
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And it's important that when you're working with patients and families, you be able to ask the question, why?
00:12:08
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You know, tell me a little bit more about why dialysis is important to you.
00:12:14
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And notice that I said to you and not necessarily to your loved one, because I think it's really hard for families to be able to have any certainty, patience for that matter even, to have any certainty about what they would want when they're really critically ill.
00:12:30
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I think very few of us have been critically ill and survived to have any sort of frame of reference to be able to make those decisions.
00:12:38
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And so I think asking this question of what do you want or what would so-and-so want if they could speak for themselves, I think is a really tricky question because for the most part, we all want to live and we all want to get better and we all want to have more time with our loved ones.
00:12:53
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That's not always a medical reality.
00:12:55
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And so beginning to ask the question of why,
00:12:59
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I think becomes paramount.
00:13:01
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Why do you want this?
00:13:02
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Why is this important to you?
00:13:04
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Why do you think this will be helpful to your loved one?
00:13:08
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And let's talk about that, I think is really helpful.
00:13:11
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And I think you hit on a very important point that goes beyond conflict discussions and medical decision making, which is just in general in medicine, but probably in life as well.
00:13:23
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We have such a focus on having the right answer where perhaps what we should be really focusing on is having the right questions.
00:13:32
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And I think that usually opens up a much broader array of options for us to learn from.
00:13:39
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I love that.
00:13:41
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So the last one, Josh, is about moral positions versus moral aporia.
00:13:46
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And I have to confess that moral aporia, I don't know if I'm pronouncing it correctly, is a concept that I learned reading your paper and I have not encountered before.
00:13:56
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Yeah, and I think that unlike, you know, positions and interests are important.
00:14:05
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Connected to each other and I think disagreement and conflict are connected as well and I think that you know positions are not Opposite of aporia.
00:14:15
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I think what I would say is a moral position by definition is a stance that a person or group of individuals takes
00:14:24
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when there is a decision to be made that has high stakes.
00:14:29
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And so, you know, again, a position would be something that is –
00:14:36
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binary.
00:14:37
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You take a stand, you make a choice, you have a strong opinion about what you think is the right thing to do.
00:14:46
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And I think that therein lies the challenge, is when you believe there is only one right answer, you eliminate all other choices and options.
00:14:57
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And I think moral aporia is sort of this
00:15:02
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idea that we all live in a state of perplexity, a state of uncertainty or ambivalence or ambiguity, and that oftentimes there's more than one right moral position that you can take.
00:15:16
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Um...
00:15:16
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And that what it really comes down to is values and perspectives and your own sort of internal moral perspective.
00:15:23
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And that just because I have a particular moral perspective doesn't mean that somebody else's perspective is inherently wrong.
00:15:30
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It's just different than mine.
00:15:32
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And so I think that that's the real danger about moral positions is that we feel so certain that we're right in our view.
00:15:39
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And the reality is we live in a world of gray.
00:15:43
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And oftentimes there is more than one
00:15:46
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reasonable moral view.
00:15:48
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And we as healthcare team members don't have moral superiority to our patients and their families.
00:15:56
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Just because we've trained in medicine or in my case, trained in medicine and ethics doesn't necessarily make me more ethical or more moral than the next person.
00:16:04
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It gives me a better understanding for some of the frameworks that can lead to moral positions.
00:16:08
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But I think that we have to be careful about having any certainty that we're absolutely right.
00:16:13
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I think it's a great reminder also what you were saying earlier about curiosity, right?
00:16:18
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That certainly sometimes can be very dangerous and it kind of narrows the ability to resolve these conflicts.
00:16:25
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And I just always find it humbling when people in healthcare actually have loved ones in the ICU.
00:16:33
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And one of the, because all of a sudden what they used to be very certain about is not so anymore.
00:16:40
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And I remember Josh, one of my more seasoned nurses had her mother in the ICU, very sick, very complicated
Framework for categorizing ICU conflicts
00:16:48
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case.
00:16:48
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And her statement to me was, Sergio, you know that if I was the nurse, I would know exactly what to do.
00:16:54
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But as a daughter, I have all these doubts.
00:16:57
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And it just illustrates how we think we know right till the situation is there.
00:17:03
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Absolutely.
00:17:05
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So as we move forward and start digging a little bit deeper, I wanted to touch a little bit on the causes of conflict.
00:17:12
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And you presented a framework for discussing the major challenges of ICU conflict that I found was very, very useful.
00:17:19
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Could you just give us a quick overview of that framework of the substantive versus process versus relational domains?
00:17:27
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Yeah, I mean, I think that, you know, a lot of this comes from the law and business literature.
00:17:33
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In fact,
00:17:35
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I reframed it from a medical perspective, but it originally came from a law journal.
00:17:42
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And the idea is that there are a number of different domains in conflict that exist.
00:17:49
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And so if you think, if you break them down, there's three big ones.
00:17:51
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There's substantive, process, and relational.
00:17:54
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I think substantive is really where someone does something that causes harm to someone else.
00:18:02
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So it can be someone telling a lie, someone behaving unethically.
00:18:07
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It can be...
00:18:10
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an adverse event or a medical error.
00:18:12
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And there's a perceived harm there.
00:18:14
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There's, there's something that happened that generate, that's the sort of the nexus of the gen, the, the, the generation of the conflict.
00:18:21
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Um,
00:18:23
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Process is really a lot about hierarchy.
00:18:26
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It's a lot about sort of the rules and regulations that are in place.
00:18:31
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So you can imagine hospital hierarchy.
00:18:34
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You can think a great example of this would be in the last couple of years was visitation during COVID.
00:18:42
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And you can imagine how visitation made it really difficult from a process standpoint for us to communicate effectively with patient family members.
00:18:50
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making decisions.
00:18:51
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A lot of this was done virtually, which made it really hard to develop relationships and also when conflict emerged to be able to resolve conflict.
00:18:59
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You're not even face-to-face with the individual or in person.
00:19:02
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They're not able to see their loved ones.
00:19:05
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You know, other hospital hierarchy around how we handle complex critical care, long-stay patients,
00:19:17
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would be other examples, any other hospital regulations that may exist.
00:19:24
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And then relational is really about communication.
00:19:28
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It's how we communicate.
00:19:30
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It's the environment of care.
00:19:31
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It's how we feel comfortable in the hospital.
00:19:35
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But families don't.
00:19:37
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All the bells and the whistles.
00:19:40
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the external pressures that exist for families, the prior experiences they may have, biases that we bring to the table, biases they bring to the table.
00:19:50
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And then our own sort of as health care team members, our own personal perspective about how things should occur.
00:19:57
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These are all sort of in the relational domain.
00:19:59
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And I think this is the predominant,
00:20:04
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area that I really focus on, I think that we should be focusing on.
00:20:08
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It's hard to address substantive and process issues on the individual doctor-patient relationship, for example, but it's the relational communication piece that I think is the one that we can impact most positively if we improve on the way we communicate with patients and families and we try to better understand their experiences.
00:20:28
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And I think also, as you said, not only it's the most important one, but we can impact the substantive problems like a disclosure of an error with better skills that really fall in the relational domain, right?
Role of communication in reducing conflicts
00:20:41
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So these are skills that can be learned and that can help facilitate conflict prevention and hopefully de-escalation.
00:20:48
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Yeah.
00:20:51
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It's not to say that adverse events and medical errors aren't also relational, because ultimately, as you disclose those, what you said is absolutely right.
00:20:59
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Having being trained in, and we've been doing this,
00:21:04
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locally now at Penn, where I also work, training faculty as a risk reduction initiative on how to deliver bad news related to adverse events and medical errors.
00:21:17
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And doing some of that simulated training has been really influential in teaching and giving opportunities to practice skills on diffusing conflict that may result
00:21:31
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related to an adverse event or medical error.
00:21:33
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And it's really all about how you communicate and how you share that information, how you partner with the family during a really vulnerable time.
00:21:40
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Yeah.
00:21:40
Speaker
And I think that when you talked about process, the thing that came to mind immediately was especially when processes are inconsistent in their application.
00:21:51
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And I could just immediately hear like inside my head when you were talking about COVID visitations, statements by family.
00:22:00
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But last week I could come or my sister could do this.
00:22:04
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And the inconsistency sometimes actually I think is a big, big source of conflict.
00:22:11
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Absolutely.
00:22:12
Speaker
So as we move forward, Josh, I know that you've talked about different triggers that can actually kind of act as catalysts for conflict to explode sometimes or to emerge very rapidly.
00:22:27
Speaker
If you want to just touch on that very, very briefly, and then we really want to go into the meat of managing conflict and what are some recommendations you have that we can apply at the bedside?
00:22:38
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Yeah, I mean, I think you could divide triggers into external and internal.
00:22:42
Speaker
And I think internal triggers are triggers that are unique to the individual patient or family member.
00:22:48
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And a lot of that is based on prior experience.
00:22:52
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So prior health care experiences, being subjected to health disparities or systemic disenfranchisement,
00:23:07
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having inter-family dynamics, which you mentioned earlier, that are really challenging.
00:23:15
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And then I think there's a lot of external triggers as well, just to name a few.
00:23:21
Speaker
You know, certainly the environment of care and feeling like it's an area that they're not comfortable in.
00:23:29
Speaker
It's our home base, right?
00:23:30
Speaker
It's where we spend all of our time working, but for families who come in, it can be really overwhelming.
00:23:34
Speaker
Obviously, policy questions that you brought up earlier, mistrust in the medical system, and then our own...
00:23:45
Speaker
values and perspectives that we bring to the table as healthcare providers when we're engaging families are just some examples of external triggers.
00:23:54
Speaker
And I think what happens is, you know, all these external and internal triggers come together and it creates this sort of perfect storm for conflict to emerge.
00:24:03
Speaker
when a seemingly straightforward question becomes one of miscommunication and can result in breakdown and trust.
00:24:13
Speaker
Absolutely.
00:24:14
Speaker
And could you comment a little bit within the context of triggers, compassion fatigue, which is a topic that we've heard a lot, especially during COVID, but I do think it's important to kind of discuss in this context.
00:24:31
Speaker
Yeah, I mean, I think that that's an extension of, you know, what I described for health care team members having their own values and perspectives is also our prior experiences.
00:24:41
Speaker
And so whenever you get compassion fatigue or emotional burnout, you get cynical.
00:24:50
Speaker
You get emotional.
00:24:53
Speaker
tired emotionally and prior experiences that you've had, especially moral distress in particular.
00:25:04
Speaker
So there's a lot of different types of distress.
00:25:05
Speaker
There's physical, emotional, spiritual, psychological, and moral are sort of the big five.
00:25:11
Speaker
And I think moral distress in particular plays a really, really powerful role in how we view future interactions.
00:25:21
Speaker
when we feel like we are forced to do something that we think is wrong for patients, it results in moral distress.
00:25:30
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And over time, it leaves a moral residue such that future experiences that remind us of prior or past experiences result in us more quickly...
00:25:47
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finding ourselves in a situation where we're uncomfortable and can't handle the situation and adapt to the situation in a positive way.
00:25:58
Speaker
And it then results in difficult interactions, difficult experiences that generate conflict.
00:26:08
Speaker
And so I think for me, that's where this idea of burnout, compassion, fatigue really, um,
00:26:16
Speaker
intersects with conflict is our own wellness, our own prior experiences, negative experiences definitely can, can poison the relationships that we have going forward with patients and families and with each other as team members.
00:26:35
Speaker
Absolutely.
00:26:36
Speaker
So we really try to focus the discussion of topics on this, on this podcast and,
00:26:43
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to bedside clinicians, physicians, and APPs practicing critical care.
Strategies for managing bedside conflict
00:26:48
Speaker
So we really want to get to actionable items that they can actually apply at the bedside in terms of managing conflict.
00:26:56
Speaker
So I would like to dive into managing conflict and how you think about it.
00:27:03
Speaker
And then maybe we can talk a little bit about some specific skills in terms of relational communication that might be worth practicing for our clinicians.
00:27:14
Speaker
Yeah, I mean, I think first thing is you've got to have sort of an intuition.
00:27:18
Speaker
You've got to develop an intuition that conflict is brewing.
00:27:21
Speaker
And I think this is harder than it sounds, because oftentimes by the time we recognize conflict, it's actually too late.
00:27:32
Speaker
trust is broken down to the point where it's going to require a great deal of time and emotional energy on our part to try to bring family members back to the table, uh, quite literally, um, and, um, renegotiate and, uh, reestablish trust.
00:27:50
Speaker
And so I think one of the key things is to have sort of that, you know, I'm a, I'm a, I'm a,
00:27:56
Speaker
Marvel fan.
00:27:57
Speaker
So I talk about sort of a Spidey sense, right?
00:28:00
Speaker
So having that intuition as it's happening before you get too far down the line that there's something not quite right that needs to be addressed and then being able to act on it quickly.
00:28:12
Speaker
And I think the second piece to that is recognizing big versus small fires.
00:28:18
Speaker
Big fires as it relates to conflict is not something that the individual provider is going to be able to put out.
00:28:26
Speaker
These are, you know, big fires, when the house is on fire, it's really calling for the fire department, right?
00:28:33
Speaker
So it's really reaching out for those resources that can intercede and provide support so that you're not sort of individually trying to address the issue.
00:28:44
Speaker
And that would be palliative care team members who have a skill set and expertise with communication.
00:28:50
Speaker
It's ethics committee members who may also serve as conflict managers if they have that training.
00:28:59
Speaker
It's ombudsman, it's transferring to a different service, transferring to a different hospital.
00:29:03
Speaker
This is really when you recognize that you're not gonna be able to solve this conflict and things are so bad that you need to take fairly drastic action
00:29:13
Speaker
And those are, just to be clear, a very, very small subset of all conflict.
00:29:18
Speaker
And I've already mentioned that conflict in and of itself is fairly rare in the ICU, at least in tractable conflict.
00:29:25
Speaker
So we're really looking, as we're thinking about training the bedside provider in conflict management techniques, we're really talking about small fires, identifying it early, something's amiss, what do I need to do to sort of repair any of the damage that's been done
00:29:42
Speaker
either directly by me or in just something that has happened in the hospital stay that has caused a patient or family member to be frustrated or feel like they're not getting their needs met.
00:29:57
Speaker
And so that's step one is being able to identify it early.
00:30:01
Speaker
And I think if I was going to give one really good
00:30:10
Speaker
I guess technique that providers could use.
00:30:14
Speaker
It would be when you're meeting with families and you have any sense that there might be some disagreement or conflict that you want to address.
00:30:23
Speaker
I'm a, I'm a really big proponent of asking the family if they're satisfied with the care that they've been, that we've been providing.
00:30:32
Speaker
you'd really be amazed to find out that there's always something that the family is wrestling with or ruminating on or an experience they had in the past that hasn't left them that they want to address and they haven't brought it up for one reason or another.
00:30:46
Speaker
It can be really nice to ask them if they're satisfied and then they say, you know, no, actually, I'm really upset about or I'm really sort of
00:30:54
Speaker
thinking a lot about when you said X. And it gives you an opportunity to be able to sort of repair things early on up front and also to reestablish trust by acknowledging and potentially apologizing for their sort of perceived experience.
00:31:10
Speaker
It's a really great way to realign things with patient families.
00:31:15
Speaker
And I want to stop there for a second because my suspicion would be that a lot of our listeners don't frequently ask that question.
00:31:24
Speaker
So I really see how this could be a very potent tool for us, right?
00:31:30
Speaker
And like you said, it's something that you can use in a preventive way.
00:31:34
Speaker
And if they say they're satisfied, you can even dig a little bit deeper to make sure that they are by asking, is there anything that we could be doing better?
00:31:41
Speaker
But I also believe that, like you said, it opens up the door for a frank discussion and for an opportunity to build or reestablish trust and acknowledge what the family is going through.
00:31:54
Speaker
So I think that's an excellent, excellent kind of nugget that I hope everybody puts in practice.
00:32:00
Speaker
Yeah, and I'm just going to, if it's okay, I'm just going to sort of take a quick tangent here and talk a little bit about communication.
00:32:09
Speaker
which I think goes hand in hand with conflict management.
00:32:14
Speaker
I think that one of the most important skills critical care providers can develop is vulnerability.
00:32:25
Speaker
I think that we're oftentimes afraid to be vulnerable because we don't want people to see that we don't have all the answers.
00:32:30
Speaker
We don't want people to see that we're not necessarily strong all the time.
00:32:36
Speaker
And we don't want people to become aware of,
00:32:40
Speaker
that we're human.
00:32:42
Speaker
And I think that being vulnerable allows you to connect really personally with families because they're also vulnerable.
00:32:51
Speaker
And so to that end, one of the things that I do when I have family meetings is I never start with the medical facts.
00:32:58
Speaker
I think we're all taught, a lot of us anyway, we're taught in medical school and residency that when you start a family meeting, you
00:33:05
Speaker
You start by trying to make sure we're all on the same page.
00:33:07
Speaker
So let's talk about the medical facts.
00:33:09
Speaker
Tell me what you know.
00:33:10
Speaker
I'll tell you what I know.
00:33:12
Speaker
We'll make sure that we have a good shared understanding.
00:33:15
Speaker
And I think that's a really important thing that we need to do.
00:33:18
Speaker
But I always start with the emotions first, because when patients are sick, their families are suffering as well.
How can healthcare providers connect with patient families?
00:33:24
Speaker
So I always start with, I imagine this has been really hard for you.
00:33:27
Speaker
Tell me how you're doing.
00:33:30
Speaker
What are you thinking about?
00:33:31
Speaker
What are you worried about?
00:33:32
Speaker
What's something that has been on your mind?
00:33:36
Speaker
Are you satisfied with the care that we're providing?
00:33:39
Speaker
Is there anything that we could do better?
00:33:41
Speaker
What are you hoping for?
00:33:42
Speaker
These are all sort of examples of questions that you could ask that allow you to test, sort of take the temperature of the family and will very quickly allow you to recognize
00:33:53
Speaker
If they're feeling vulnerable, sad, guilty, angry, frustrated, what emotions are they experiencing so that you can begin to sort of peel back the layers of that first and address those things before you get to the meat of the conversation, which is,
00:34:12
Speaker
How are we going to do what we need to do for your loved one who's in the bed, sick and dying?
00:34:17
Speaker
So I really am a big proponent of starting with sort of the emotional aspects of care for the family members who are really our patients by extension.
00:34:25
Speaker
And I think, Josh, that along those lines of vulnerability and how you open up discussions, a skill that is very important to develop is just naming emotions.
00:34:35
Speaker
Right.
00:34:36
Speaker
And we're not very good at that in general.
00:34:38
Speaker
But like I sense you are angry.
00:34:40
Speaker
Is that correct?
00:34:41
Speaker
Tell me more about it.
00:34:42
Speaker
Right.
00:34:43
Speaker
And most people in your position would probably feel overwhelmed.
00:34:46
Speaker
I mean, that's kind of name the emotions that you are sensing or even that you are feeling sometimes, like you said,
00:34:52
Speaker
is a way of enhancing that vulnerability discussion.
00:34:57
Speaker
Yeah, that's right.
00:34:58
Speaker
It's the old nurse mnemonic, uh, that was developed in the oncology world, but certainly has found itself into critical care.
00:35:05
Speaker
Absolutely.
00:35:07
Speaker
Can you talk a little bit about active listening as a skill and communication that I believe we should all work on?
00:35:16
Speaker
Yeah, boy.
00:35:16
Speaker
I mean, that's, there's a lot to unpack there.
00:35:18
Speaker
Um,
00:35:19
Speaker
I think I would say two things that are critical with active listening.
00:35:26
Speaker
One is quite literally spending most of your time listening rather than speaking.
00:35:34
Speaker
And the second is really internalizing what the individual is saying and making sure that you understand what they're saying and that you demonstrate curiosity and ask questions about what they're saying to try to continue to peel back those layers
00:35:55
Speaker
to gain as much nuance and as much clarity in their perspective and their narrative, their experiences, to help you help them make the best choices that we can for their loved ones.
00:36:11
Speaker
Excellent.
00:36:12
Speaker
And one of the topics that we frequently discuss, obviously, in medicine is empathy.
00:36:21
Speaker
And there are skills to be more empathic.
00:36:24
Speaker
Could you give us maybe some examples of how you would acknowledge or validate what other individuals are struggling with when you're having these discussions?
00:36:36
Speaker
Yeah, I mean, you know, validating emotions is really just letting them know that what they're feeling and what they're saying is okay.
00:36:52
Speaker
and that whether I agree with it or not, that is their reality and that I respect that.
00:37:00
Speaker
So, you know, being able to validate what they're saying is just literally that, being able to say, you know, I imagine from your point of view or what I'm hearing you say, sort of, again, using those active listening skills and being able to say it's okay to feel that way or many people in your situation would feel exactly the same way is really,
00:37:27
Speaker
you know, how you, how you start to validate people's experiences and then asking more questions about it.
00:37:33
Speaker
Right.
00:37:34
Speaker
Again, being, being curious.
00:37:36
Speaker
Definitely.
00:37:37
Speaker
Is there a place in these communication or these conversations to express regret?
00:37:44
Speaker
Oh, 100%.
00:37:45
Speaker
Absolutely.
00:37:46
Speaker
Expressions of regret and remorse are fantastic ways to align yourself with the families.
00:37:51
Speaker
Again, when you're in a situation where there's conflict, by definition, there are at least two parties who have a differing perspective or viewpoint, and those viewpoints are clashing.
00:38:02
Speaker
And so especially when someone is expressing moral distress, when someone feels that you have...
00:38:11
Speaker
somehow morally harmed them.
00:38:12
Speaker
They're angry.
00:38:15
Speaker
They're resentful.
00:38:16
Speaker
They are indignant of something that you've done.
00:38:21
Speaker
So something that I have done to you has caused harm.
00:38:25
Speaker
Now, that may just be their perception.
00:38:27
Speaker
It may not be that I actually have done something.
00:38:29
Speaker
But the reality is, when they feel that way, it really doesn't matter whether or not
00:38:35
Speaker
I did it because their perspective is I've harmed them.
00:38:39
Speaker
And so being able to say, I'm really sorry that you're having this experience or being able to say, I wish things were different.
00:38:50
Speaker
Expressing regret is a critical skill to develop and something that you should not be afraid to do.
00:38:57
Speaker
And so some listeners are going to say, well, you know, what about tort claims?
00:39:01
Speaker
What about being sued for saying, I'm sorry?
00:39:04
Speaker
And
00:39:05
Speaker
I don't want to get too much into the nuance of that, but I will say that there are partial apology states and total apology states, and in total apology states, you're protected from any expression of apology, any statement you make, even demonstrating that you've done something wrong.
00:39:25
Speaker
actually wrong can't be used against you.
00:39:28
Speaker
In a partial apology state, you know, let's say you do a procedure and it causes harm.
00:39:33
Speaker
If you were to say, I'm sorry that I did that, it could be potentially used against you.
00:39:38
Speaker
But if you were to say, I wish things were different, I'm sorry that you've had this experience, those are perfectly safe and they're great ways for family members to feel like you're validating their lived experience and their narrative.
00:39:51
Speaker
Excellent.
00:39:52
Speaker
And the last skill, which I think is ultimately towards the closing of any conflict, de-escalation, resolution, or trying to bring the temperature down is compromise.
00:40:05
Speaker
Any comments on compromising?
00:40:09
Speaker
Yeah, I mean, I think...
00:40:13
Speaker
First of all, you don't want to compromise your own moral integrity.
00:40:16
Speaker
So if someone is asking you to do something that's just frankly medically inappropriate, you have to be able to say, that's not something that I can do.
00:40:29
Speaker
But the idea of compromise really comes from this philosophy of finding a win-win.
00:40:35
Speaker
And I think this is one of the most important aspects of understanding conflict management, which is to say that by definition, when there's conflict, there's typically a winner and a loser.
00:40:46
Speaker
When people walk away from the table after arbitration or mediation in the business world or the law world or after meeting with a family member in the ICU, you don't want to win-lose because somebody walks away upset.
00:41:01
Speaker
Someone walks away feeling like they were not able to get their needs met.
00:41:05
Speaker
So what you're looking for is a win-win where everyone walks away not necessarily getting what they want but feeling like they were heard
00:41:12
Speaker
They were validated.
00:41:13
Speaker
They had an opportunity to express their perspective.
00:41:17
Speaker
And that in the end, the outcome was something they can live with, even if it's not exactly what they wanted.
00:41:22
Speaker
And that leads to something called catharsis, which is healing.
00:41:28
Speaker
It's an opportunity for you to feel like that anger, that frustration, that whatever that experience was that was causing distress has been alleviated.
00:41:42
Speaker
And so I think, you know, that's what compromise is really about.
00:41:45
Speaker
And I even will do that with families.
00:41:47
Speaker
I'll say, you know, it sounds like we're on a different page.
00:41:51
Speaker
I know we both want to do everything we can,
00:41:56
Speaker
For mom, I know how much you care about her, we care about her too.
00:42:01
Speaker
And the fact that we disagree doesn't mean that anyone's wrong, it just means that we have a different perspective.
00:42:05
Speaker
And let's try and find a way to compromise to find an outcome that would be meaningful to you, but also would feel like we're doing the right thing medically based on what we know about her illness and her likely outcome.
00:42:22
Speaker
And then the other thing that I really have internalized, you know, a number of years ago now that I teach to my trainees is that in the end, you're not the one in the bed and your loved one isn't the one in the bed.
00:42:34
Speaker
It's a patient and their family's suffering.
00:42:37
Speaker
And so I live by a mantra that if it's meaningful for you, it's meaningful for me.
00:42:43
Speaker
I may not agree with the decision ultimately, but if it helps the family understand
00:42:50
Speaker
cope with their loved one's demise, then I'm okay doing most things for patients, at least on the short term, to allow the family a little bit more time to accommodate to the realities.
00:43:06
Speaker
And that's really what this is about ultimately, is trying to help them through this experience so that their narrative is that in the end, not necessarily that we did everything,
00:43:16
Speaker
that we could, but that we really tried as hard as possible to meet their needs and to support them through their loved ones critical illness.
00:43:25
Speaker
Absolutely.
00:43:26
Speaker
And I think as we close, I want to be respectful of your time, Josh.
Resources for managing severe conflicts
00:43:31
Speaker
It's important to emphasize that, A, we have in many hospitals resources for when conflict is really, really ingrained.
00:43:38
Speaker
And like you said, it's a major conflict disaster in terms of our supportive medicine teams, our ethics committee.
00:43:46
Speaker
But also what I feel, and please comment briefly, is that we talked a lot about conflict between the team, the ICU team and families and patients.
00:43:57
Speaker
But this can also be applied, all the tools you talked about, to conflict with our CT surgery team, with our oncology team, or with other teams that are caring for patients with us in the ICU.
00:44:11
Speaker
Yeah, I mean, everyone has a reason for feeling the way they feel.
00:44:16
Speaker
I've had many experiences where a consultant came into the ICU and had a very strong, equally valid, though completely different perspective about a patient and the care that's being provided, or even a difference of opinion between healthcare team members within the ICU, so the nurse versus the doctor.
00:44:41
Speaker
you know, this is going to happen.
00:44:42
Speaker
We're all human beings and we all have our own biases.
00:44:47
Speaker
We all have our own perspectives.
00:44:49
Speaker
And so showing that curiosity, being able to say, well, tell me a little bit more about why you feel that way is, is a valuable skill to develop, not just for patients and families, but also within our teams.
00:45:03
Speaker
Yeah.
00:45:04
Speaker
Excellent.
00:45:05
Speaker
So we like to close every episode of the podcast with a couple of questions that are unrelated to the topic we discussed.
00:45:11
Speaker
Would that be okay, Josh?
00:45:13
Speaker
Absolutely.
00:45:14
Speaker
Is there a book or books that have influenced you the most or a book that you have gifted most often to others?
00:45:22
Speaker
Yes.
00:45:23
Speaker
So I run the ICU communication curriculum for our pulmonary and critical care fellows at Penn.
00:45:31
Speaker
And in the last couple of years, I've been gifting them with a copy of In Shock by Rana Audish.
00:45:38
Speaker
She is a colleague in pulmonary critical care up at Henry Ford in Detroit.
00:45:43
Speaker
And it is a beautiful, beautiful first-person narrative of her experience with illness and critical illness and actually having a cardiopulmonary arrest and being resuscitated and what she learned as a patient that has changed the way she practices medicine and the way she approaches care.
00:46:05
Speaker
And if I can offer just one brief moment from that book that really has stuck with me, she talks about
00:46:13
Speaker
patients and families at the edge of a cliff looking over the abyss, into the abyss, being critical illness, and that we in healthcare have this idea in our minds that we're there with our backs to the cliff trying to keep the patient or family member from falling off.
00:46:32
Speaker
And that in reality, what we should be doing is standing side by side, facing the abyss, hand in hand, trying to care for our patients and their loved ones, because we can't always stop death.
00:46:47
Speaker
We can't always cure critical illness, but we can always be a witness to the suffering of the patients and families that we're caring for.
00:46:54
Speaker
And that in and of itself is incredibly restorative for us as human beings and as practitioners of critical care.
00:47:02
Speaker
And I just think it's a beautiful analogy that we should embrace as healthcare providers.
00:47:09
Speaker
Absolutely.
00:47:11
Speaker
Everyone should read that book.
00:47:12
Speaker
It's really, really powerful.
00:47:13
Speaker
And we'll include it in the links in the show notes.
00:47:17
Speaker
And the last and closing question is, what would you want every listener, every intensivist who's listening to us today to know?
Promoting self-compassion for healthcare providers
00:47:27
Speaker
Just have compassion for yourself.
00:47:29
Speaker
What we do is really hard.
00:47:32
Speaker
Um, and it, it's, you don't have to just think about the last two years of COVID care to recognize that, um, taking care of sick and dying patients is a really difficult thing to do.
00:47:48
Speaker
And, you know, we are almost like, um, the fire department when the building is burning and everyone's running, we go into the building.
00:47:57
Speaker
And it is easy to get cynical.
00:48:01
Speaker
It's easy to get emotionally fatigued.
00:48:03
Speaker
It's easy to be morally distressed.
00:48:06
Speaker
But what we do is so profound and so important.
00:48:10
Speaker
And the opportunity that we have to help be a witness to the suffering of family members when their loved ones are dying is
00:48:18
Speaker
is a real gift.
00:48:20
Speaker
And we're not always going to get it right every time.
00:48:22
Speaker
We're not always going to be the best versions of ourselves.
00:48:25
Speaker
But have compassion for yourself.
00:48:27
Speaker
Do things that make you happy.
00:48:29
Speaker
Do things outside of work that sustain you.
00:48:33
Speaker
Talk about those tough experiences.
00:48:35
Speaker
Write about it.
00:48:36
Speaker
Journal it.
00:48:38
Speaker
Debrief it.
00:48:39
Speaker
And just sustain yourself in any way you can because the world is a better place for what we do.
00:48:46
Speaker
Absolutely.
00:48:47
Speaker
And I think that's a perfect place to
Conclusion and subscriptions
00:48:49
Speaker
stop.
00:48:49
Speaker
I want to thank you for your time, for sharing your expertise, and definitely hope to have you back on the podcast soon.
00:48:56
Speaker
I would love that anytime.
00:48:57
Speaker
Thanks for having me.
00:48:58
Speaker
Thank you, Josh.
00:49:01
Speaker
Thank you for listening to Critical Matters, a sound podcast.
00:49:05
Speaker
Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
00:49:10
Speaker
Sound's transforming the way critical care is provided in hospitals across the country.
00:49:15
Speaker
To learn more, visit www.soundphysicians.com.