7. Conflicts with family and among professionals

## 7.1. Basic ideas

Disagreements can arise in several aspects: patient's prognosis and wishes; points of view about what is a successful outcome or a good prognosis; understanding of cultural and religious values; the family fell responsible of the death of the patient; emotional overlap of previous unsatisfactory interactions between health personnel and the patient or their family. These disagreements can also arise at different levels: between family members, between family and doctors, and even between different medical teams. The desire to avoid a painful treatment or dependency is often as important for the patient as the possibility of survival; therefore, the probable prognosis should be included in the discussion. The disagreement taken to the extreme, or extreme disagreement, is the conflict.

### 7.2. Conflicts between family members and medical team

An open and early communication about the risk of death is a priority in critical situations. The patient and his/her family will be offended and will resist the withdrawal of the treatment if the death expectancy is discovered at the end of the course of the disease.

The advantages of the medical consensus decision are important, but if this can't be achieved, both options should be presented to the patient and family. Patients and family members may find themselves confused if the treatment options and the possibility of interrupting any of them are carried out at a late stage in the evolution. Honest, sincere, and precocious commu-

• circular conversations: the family avoids discussing withdrawal of treatment and revisits previous discussions repeatedly. The solution to this problem is to stop and announce the discussion topic (ensure that the discussion is

• criticism or rejection of individual members of the team, especially nurses, and accusations of not attending

• request that a specific treatment be administered or interrupted (for example, withdrawal of opiates by the belief that they have been deliberately administered to shorten life). Petitions and demands can be increasingly inappro-

• request to see the medical records, with the help of a member of the team to clarify doubts

properly or incompetence; in a extreme case, transfer requests to another ICU

priate if the process continues, until attempts to control medical decisions.

• request for second opinions: can be sought in the ICU or out of it, including people without medical knowledge, or

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The word "die" should be used if death is a nonremote possibility. Here is an example: "It is very likely that you will die from this disease, we are doing the indicated treatment, we would like to talk again tomorrow in the morning and tell you if this situation has changed or not, we

Conflict prevention is an essential part of communicating with patients, family and nonmedical

• take the appropriate time (unless it is an emergency); families need time to understand at their own pace, often with discussion at home, rather than being forced by the medical

• if this is the case, explain to the family that the decisions about the interruption of a

• facilitate a second opinion if the family requests it and that this "external opinion" has access to all available information; Sometimes, a general practitioner (GP) in whom the family has confidence, with their own ethnic values, will probably understand the medical situation and may communicate it to the family in an appropriate manner. Others, how-

• in some circumstances, the presence of an involved third party (facilitator) can clarify and

When the aforementioned steps have not resolved the dispute, and although rarely effective, the possibility of transferring the patient to another ICU should be considered. Finally, the courts and the Supreme Court can intervene in situations with no way out. If an organization

ever, as alternative healers, may not make progress in understanding the case.

nication is always the best option.

staff. Here are some key points:

team;

focused)

religious beliefs

are offering you the best treatment available".

• avoidance behaviors of medical or ICU personnel,

Table 3. Elements that are associated with end of life conflicts.

treatment are based on consensus;

address the concerns of the patient and their family.

The possible outcomes should be early discussed with the patient and his family, especially if the patient is seriously ill. An honest and sensitive communication, from the beginning of the disease, on the risk of death makes all parties aware of the possible evolutionary courses, and creates the confidence necessary for joint decision-making and preventing most disagreements.

As already mentioned, doctors consider an appropriate treatment according to the possibility of survival, but the treatment burden, the expected duration of the treatment and the probable prognosis are important aspects for the patient and his family.

The communication must be early and proactive, it must clarify the objectives of the treatment and guide the treatment plan to the patient's values. Listening and empathizing with the opinions of the other party is a way to handle any disagreement. The conflict can be harmful for all parties, and it is better to prevent or treat it early to avoid the negative effects [20].

When detecting these behaviors, a plan should be drawn that prevents the progression of these behaviors. The family that experiences a conflict should receive adequate support. Health personnel should provide clear information, thus avoiding the deterioration of relationships. Finally, threats to health personnel should not be tolerated.

Despite good communication training and proper family management, there may be families with a different perspective of intensive care and management of the patient's end of life. Some sensitive families may not assimilate the information. Families may not be aware of the patient's wishes. The explanation that the treatment plan is made based on your wishes can help resolve the conflict.

Several indicators of conflict regarding end-of-life care can be recognized (Table 3).


7. Conflicts with family and among professionals

taken to the extreme, or extreme disagreement, is the conflict.

7.2. Conflicts between family members and medical team

prognosis are important aspects for the patient and his family.

Finally, threats to health personnel should not be tolerated.

help resolve the conflict.

the death expectancy is discovered at the end of the course of the disease.

Disagreements can arise in several aspects: patient's prognosis and wishes; points of view about what is a successful outcome or a good prognosis; understanding of cultural and religious values; the family fell responsible of the death of the patient; emotional overlap of previous unsatisfactory interactions between health personnel and the patient or their family. These disagreements can also arise at different levels: between family members, between family and doctors, and even between different medical teams. The desire to avoid a painful treatment or dependency is often as important for the patient as the possibility of survival; therefore, the probable prognosis should be included in the discussion. The disagreement

An open and early communication about the risk of death is a priority in critical situations. The patient and his/her family will be offended and will resist the withdrawal of the treatment if

The possible outcomes should be early discussed with the patient and his family, especially if the patient is seriously ill. An honest and sensitive communication, from the beginning of the disease, on the risk of death makes all parties aware of the possible evolutionary courses, and creates the confidence necessary for joint decision-making and preventing most disagreements.

As already mentioned, doctors consider an appropriate treatment according to the possibility of survival, but the treatment burden, the expected duration of the treatment and the probable

The communication must be early and proactive, it must clarify the objectives of the treatment and guide the treatment plan to the patient's values. Listening and empathizing with the opinions of the other party is a way to handle any disagreement. The conflict can be harmful for all parties, and it is better to prevent or treat it early to avoid the negative effects [20].

When detecting these behaviors, a plan should be drawn that prevents the progression of these behaviors. The family that experiences a conflict should receive adequate support. Health personnel should provide clear information, thus avoiding the deterioration of relationships.

Despite good communication training and proper family management, there may be families with a different perspective of intensive care and management of the patient's end of life. Some sensitive families may not assimilate the information. Families may not be aware of the patient's wishes. The explanation that the treatment plan is made based on your wishes can

Several indicators of conflict regarding end-of-life care can be recognized (Table 3).

7.1. Basic ideas

38 Reflections on Bioethics


Table 3. Elements that are associated with end of life conflicts.

The advantages of the medical consensus decision are important, but if this can't be achieved, both options should be presented to the patient and family. Patients and family members may find themselves confused if the treatment options and the possibility of interrupting any of them are carried out at a late stage in the evolution. Honest, sincere, and precocious communication is always the best option.

The word "die" should be used if death is a nonremote possibility. Here is an example: "It is very likely that you will die from this disease, we are doing the indicated treatment, we would like to talk again tomorrow in the morning and tell you if this situation has changed or not, we are offering you the best treatment available".

Conflict prevention is an essential part of communicating with patients, family and nonmedical staff. Here are some key points:


When the aforementioned steps have not resolved the dispute, and although rarely effective, the possibility of transferring the patient to another ICU should be considered. Finally, the courts and the Supreme Court can intervene in situations with no way out. If an organization experiences repeated conflicts about the end of life, the established protocols on this matter should be reviewed.

In case of increased difficulty, over the years between medical teams, the doctors involved should take further measures to get an acceptable consensus for the medical team and may

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Conflicts in relation to end-of-life decisions may reappear. When an intervention or procedure has been developed, the other specialist may find it difficult to withdraw the treatment, especially if he has invested a lot of time and effort in that solution. Empathy with the family has traditionally been emphasized, but the relationship with other doctors is also important.

Doctors must always adhere to the Code of Good Medical Conduct [5]. These good behaviors require doctors to communicate effectively with other team members, and the consequences of bullying and aggression must be made clear. Some doctors can maintain a position of conscientious objection in relation to end-of-life management; in these cases, the doctor should stop

Sometimes conflicts arise between the family members, and health personnel must help by providing clear information and helping to minimize the breakdown and damage of relationships. Long relationships are tested by emotion, fatigue, or interest in the patient. The ICU environment can generate positive emotional responses and unmask previous tensions, for example, unrecognized sentimental relationships, habits, practices or orientations of the

There is no single solution to these situations. It may be necessary the support of social workers, priests, family counselors, and even security guards. First of all, UCI staff cannot lose sight of their primary responsibility for the patient, although the duty of care can be extended

There may be serious disagreements involving patients and their families. The wishes of a patient who maintains their ability to make decisions are supreme and remain so when they have been expressed in advance. If the wishes about acceptance or rejection of active treatment are known, the wishes of the patient should prevail over those of his family. It is important to explore why the family wants to disobey the patient's wishes or believes that their wishes are

The request of the family that the patient should not be informed should be managed with great care. On these occasions, the family should be informed that the patient has the right to choose if they are going to be fully informed. The family should be told that most patients want to be informed, and that the intensivists are very careful and compassionate in their explanations. The family will be notified that the patient will be asked, with the family present, if he wants that the family is informed. Most patients do not want to be excluded and the patient's preference for the inclusion of their family in the information must be respected. Few patients want to be protected

involve the hospital's medical administration or human resources.

Without empathy, problems may reappear.

7.4. Conflict between family members

to the interests of the patient's family.

7.5. Conflict between the patient and his/her family

patient, etc.

not valid.

evaluating the aspects related to the patient's care.

#### 7.3. Conflict between medical teams

There may also be a lack of agreement between two medical teams and may be due to several factors.


Respect must be shown to the other doctor, and if necessary, involve a veteran colleague to help resolve the conflict. It is important that doctors respect the disagreement that may exist between them, and recognize the need for consensus, accepting it. There must be a desire to negotiate and to remain objective, and on all occasions, to maintain the focus on the patient's best interests.

Conflict is considered a burden on all sides, and has been associated with symptoms of posttraumatic stress and burn-out syndrome [21]. Disagreement among the treatment objectives is the most common source of conflict among ICU staff [22], although disagreement about prognosis is also frequent. Occasionally, doctors and nurses may be forced to apply treatments at the request of the family or other medical teams, and that they do not believe follow the best interests of the patient. This can make them feel undervalued and lead to a moral conflict with short- and long-term consequences. Active professional support programs should be part of the routine functioning of the ICU, with professional advice and supervision for those with exposure to complicated end-of-life decision-making situations.

There is a general belief that the intensivists are downright pessimistic and that the doctors of other teams are too optimistic [23, 24]. All specialties must be aware of the prognostic uncertainty of the critical patient and of the primacy of the personal values and the quality of life of the patients facing the burden and the benefit of the treatment. Misunderstandings can be avoided if the other medical teams visit the ICU frequently and keep informed of the patient's progress. No doctor has the right of veto over other doctors. Although it is useful to consider how much weight, it is reasonable to have the point of view of each specialist when reaching an agreement. A specialist who has taken the patient for a long time, or who has special knowledge about the prognosis of the disease in particular, can provide useful information.

In case of increased difficulty, over the years between medical teams, the doctors involved should take further measures to get an acceptable consensus for the medical team and may involve the hospital's medical administration or human resources.

Conflicts in relation to end-of-life decisions may reappear. When an intervention or procedure has been developed, the other specialist may find it difficult to withdraw the treatment, especially if he has invested a lot of time and effort in that solution. Empathy with the family has traditionally been emphasized, but the relationship with other doctors is also important. Without empathy, problems may reappear.

Doctors must always adhere to the Code of Good Medical Conduct [5]. These good behaviors require doctors to communicate effectively with other team members, and the consequences of bullying and aggression must be made clear. Some doctors can maintain a position of conscientious objection in relation to end-of-life management; in these cases, the doctor should stop evaluating the aspects related to the patient's care.

### 7.4. Conflict between family members

experiences repeated conflicts about the end of life, the established protocols on this matter

There may also be a lack of agreement between two medical teams and may be due to several

• personal refusal to accept death as a result, including feelings of guilt (frequent in the case

• emotional overload, frequent in situations of previous unsatisfactory interaction with the

Respect must be shown to the other doctor, and if necessary, involve a veteran colleague to help resolve the conflict. It is important that doctors respect the disagreement that may exist between them, and recognize the need for consensus, accepting it. There must be a desire to negotiate and to remain objective, and on all occasions, to maintain the focus on the patient's

Conflict is considered a burden on all sides, and has been associated with symptoms of posttraumatic stress and burn-out syndrome [21]. Disagreement among the treatment objectives is the most common source of conflict among ICU staff [22], although disagreement about prognosis is also frequent. Occasionally, doctors and nurses may be forced to apply treatments at the request of the family or other medical teams, and that they do not believe follow the best interests of the patient. This can make them feel undervalued and lead to a moral conflict with short- and long-term consequences. Active professional support programs should be part of the routine functioning of the ICU, with professional advice and supervision for those with

There is a general belief that the intensivists are downright pessimistic and that the doctors of other teams are too optimistic [23, 24]. All specialties must be aware of the prognostic uncertainty of the critical patient and of the primacy of the personal values and the quality of life of the patients facing the burden and the benefit of the treatment. Misunderstandings can be avoided if the other medical teams visit the ICU frequently and keep informed of the patient's progress. No doctor has the right of veto over other doctors. Although it is useful to consider how much weight, it is reasonable to have the point of view of each specialist when reaching an agreement. A specialist who has taken the patient for a long time, or who has special knowledge about the prognosis of the disease in particular, can provide useful

should be reviewed.

40 Reflections on Bioethics

factors.

patient.

best interests.

information.

7.3. Conflict between medical teams

• disagreement about the prognosis;

of iatrogenic complications);

• different concepts about what "treatment success" represents;

• different understanding of what the patient wants;

• doubts about administrative or legal requirements;

exposure to complicated end-of-life decision-making situations.

Sometimes conflicts arise between the family members, and health personnel must help by providing clear information and helping to minimize the breakdown and damage of relationships. Long relationships are tested by emotion, fatigue, or interest in the patient. The ICU environment can generate positive emotional responses and unmask previous tensions, for example, unrecognized sentimental relationships, habits, practices or orientations of the patient, etc.

There is no single solution to these situations. It may be necessary the support of social workers, priests, family counselors, and even security guards. First of all, UCI staff cannot lose sight of their primary responsibility for the patient, although the duty of care can be extended to the interests of the patient's family.

#### 7.5. Conflict between the patient and his/her family

There may be serious disagreements involving patients and their families. The wishes of a patient who maintains their ability to make decisions are supreme and remain so when they have been expressed in advance. If the wishes about acceptance or rejection of active treatment are known, the wishes of the patient should prevail over those of his family. It is important to explore why the family wants to disobey the patient's wishes or believes that their wishes are not valid.

The request of the family that the patient should not be informed should be managed with great care. On these occasions, the family should be informed that the patient has the right to choose if they are going to be fully informed. The family should be told that most patients want to be informed, and that the intensivists are very careful and compassionate in their explanations. The family will be notified that the patient will be asked, with the family present, if he wants that the family is informed. Most patients do not want to be excluded and the patient's preference for the inclusion of their family in the information must be respected. Few patients want to be protected

from information, and expect their family to take a decision-making role; this is acceptable if the intensivist perceives that the decision is taken freely and without coercion, clarifying that in addition to delegating the information, decision-making is delegated.

• 5th, evaluation of the doctor, based on the limited knowledge of the patient, based on

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The ACP process is developed with personnel that support health professionals, with the help of their families, to reflect their values and preferences for current and future treatments. These preferences will guide doctors and the family in providing appropriate medical treatment in the best interests of the patient [26]. It also allows registering the preference over certain

It is advisable that the ACP be discussed at the out-of-hospital level, with a GP or at the geriatric care center, without stress that implies an acute medical condition. This allows individuals, with the support of their families, to have time to discuss, reflect, and identify what is really important for them to "live well" and "die well." However, ACPs that are made in the hospital are also considered valid, even those made in extreme situations (for example, preoperative). GPs, in which the patient has placed their trust, are basic for the initiation of ACP discussions [27] and can be introduced in their routine evaluation, in case there is any change in the general situation of the patient. This confection is associated with greater family

ACP is usually performed in hospitals with discussions with nurses for 20–45 minutes, which is accompanied by greater congruence between the patient and the substitute decision-maker, a feeling of being better informed, more confident in knowing benefits and loads of proposed treatments, and feeling that less pressure is transmitted in the decisions to be made [29] (although other works show the contrary, more discussions between patients and substitute decision-makers for end-of-life decisions) [30]. Intensivists should follow the expressed preferences of the patient, except if there is a good reason to believe that the preference of the patient

The death of a patient after carrying out an LLTS plan is a very complex situation, and the way in which patients die and families coexist with it is variable. The palliative care plan should be individualized to the particular needs of each case and should include pharmacological and nonpharmacological measures. Practical and emotional support should also be offered explaining that dying could cause the presence of noisy and agonizing breathing. Attention should be paid to these signs (especially when they appear as a result of the withdrawal of respiratory support) to administer preventively sedation and analgesia; the withdrawal of renal or cardiovascular treatment does not require support measures for de-scaling. Palliative treatments will always be administered with the intention of relieving symptoms, not accelerating death. Properly document what therapies are removed such as mechanical ventilation,

what other patients have wanted to do in similar circumstances.

satisfaction in caring for him [28].

changed recently.

equipment

9.1. Patient care

treatments or documenting your point of view about an unacceptable evolution.

9. Care of the patient who dies imminently; family and medical

dialysis, inotropes, cardiopulmonary resuscitation, etc.

## 8. Decision-making, advance care planning, advance care decision

The treatment of critically ill patients has two objectives: intensive treatment, which tries to restore the health and functionality of the patient to a level acceptable to him, and the control of symptoms, which tries to reduce the burden of suffering caused by the disease and by your treatment. In certain cases, in the face of poor clinical evolution, pursuing the best interest of the patient is to change the treatment approach from intensive treatment to palliative care, rather than extending life in any way [25]. Applying the principles of palliative care means maintaining comfort and dignity, attending to psychological and spiritual needs, and supporting the family.

Doctors and family members must make decisions based on the wishes of the patient. He has sometimes made ACP or formal opinion heard. But those desires can also be deduced in other ways: extrapolation of how he has led his life, general statements during his life, and sometimes appointment of a substitute decision-maker (who will inform the medical team of their preferences regarding this point if the patient cannot).

ACP allows the patient to plan and make clear his preferences and to take care of his health in case he gets sick. They usually include end-of-life decisions (although not necessary). It is based on the principle of Autonomy, and on the right to be fully informed about the treatment options of their pathology, and to be treated in a way that respects their dignity and avoids their suffering. ACP improves end-of-life care, meets the preferences expressed by the patient, improves family satisfaction, and reduces anxiety depression and the post-traumatic effect on survivors. It should be reflected in writing (ACD) and included in the medical report, with an adequate alert system. The intensivists must be familiar with their inclusion in the decisionmaking of patients, especially in end-of-life treatments.

However, the ACP may be inadequate to provide the degree of certainty necessary to support the end-of-life decision, for example, to include generic phrases such as "no reasonable possibility of cure." It can be established an order of reliability about the validity of the patient's wishes:


• 5th, evaluation of the doctor, based on the limited knowledge of the patient, based on what other patients have wanted to do in similar circumstances.

The ACP process is developed with personnel that support health professionals, with the help of their families, to reflect their values and preferences for current and future treatments. These preferences will guide doctors and the family in providing appropriate medical treatment in the best interests of the patient [26]. It also allows registering the preference over certain treatments or documenting your point of view about an unacceptable evolution.

It is advisable that the ACP be discussed at the out-of-hospital level, with a GP or at the geriatric care center, without stress that implies an acute medical condition. This allows individuals, with the support of their families, to have time to discuss, reflect, and identify what is really important for them to "live well" and "die well." However, ACPs that are made in the hospital are also considered valid, even those made in extreme situations (for example, preoperative). GPs, in which the patient has placed their trust, are basic for the initiation of ACP discussions [27] and can be introduced in their routine evaluation, in case there is any change in the general situation of the patient. This confection is associated with greater family satisfaction in caring for him [28].

ACP is usually performed in hospitals with discussions with nurses for 20–45 minutes, which is accompanied by greater congruence between the patient and the substitute decision-maker, a feeling of being better informed, more confident in knowing benefits and loads of proposed treatments, and feeling that less pressure is transmitted in the decisions to be made [29] (although other works show the contrary, more discussions between patients and substitute decision-makers for end-of-life decisions) [30]. Intensivists should follow the expressed preferences of the patient, except if there is a good reason to believe that the preference of the patient changed recently.
