Article Text
Abstract
Conflict is an important consideration in the intensive care unit (ICU). In this setting, conflict most commonly occurs over the ‘best interests’ of the incapacitated adult patient; for instance, when families seek aggressive life-sustaining treatments, which are thought by the medical team to be potentially inappropriate. Indeed, indecision on futility of treatment and the initiation of end-of-life discussions are recognised to be among the greatest challenges of working in the ICU, leading to emotional and psychological ‘burnout’ in ICU teams. When these disagreements occur, they may be within the clinical team or among those close to the patient, or between the clinical team and those close to the patient. It is, therefore, crucial to have a theoretical understanding of decision-making itself, as unpicking misalignments in the family’s and clinical team’s decision-making processes may offer strategies to resolve conflict. Here, we relate Kahneman and Tversky’s work on cognitive biases and behavioural economics to the ICU environment, arguing that these biases could partly explain disparities in the decision-making processes for the two conflicting parties. We suggest that through the establishment of common ground, challenging of cognitive biases and formulation of mutually agreeable solutions, mediation may offer a pragmatic and cost-effective solution to conflict resolution. The litigation process is intrinsically adversarial and strains the doctor–patient–relative relationship. Thus an alternative external party should be considered, however mediation is not frequently used and more research is needed into its effectiveness in resolving conflicts in the ICU.
- ethics
- end of life care
- capacity
- decision-making
- psychology
This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.
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Footnotes
Twitter @harleen_johal, @medic_mediator
Contributors CD conceived the ideas presented. HKJ developed the content of these ideas and wrote the first draft, in consultation with CD. Both authors edited and approved of the final manuscript.
Funding This work was, in part, funded by the ‘Balancing Best Interests in Health Care, Ethics and Law (BABEL)’ Collaborative Award from the Wellcome Trust (209841/Z/17/Z).
Disclaimer The funding body played no role in the writing of the manuscript.
Competing interests Dr Christopher Danbury is a trained mediator, who is on the clinical negligence panel of Trust Mediation. Trust Mediation is one of the panel organisations approved by NHS Resolution for its mediation.
Provenance and peer review Not commissioned; externally peer reviewed.
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