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Communication Strategies to Address Conflict about Dialysis Decision Making for Critically Ill Patients

2018; Lippincott Williams & Wilkins; Volume: 13; Issue: 8 Linguagem: Inglês

10.2215/cjn.00010118

1555-905X

Jane O. Schell, Robert A. Cohen,

Patient Dignity and Privacy

Case Presentation A 65-year-old man with alcoholic cirrhosis is transferred from another hospital with liver failure, gram-negative sepsis, and AKI due to type 1 hepatorenal syndrome. He is started on octreotide, midodrine, and albumin. Because of infection and recent alcohol use, the consulting hepatologist deems him not a transplant candidate, recommends reassessment after 6-month sobriety, and signs off. The patient's condition worsens prompting transfer to the intensive care unit where he develops oliguria. His Model of End Stage Liver Disease (MELD) score is 35, predicting 79% mortality in 3 months. Dr. Z, the intensivist, consults nephrology for "dialysis initiation." Dr. Y, the nephrologist rounding on a busy consult service, receives the page and sighs "Does Dr. Z really think dialysis is going to fix everything?" Frustrated, she calls Dr. Z to discuss the consult. Dr. Y: "Why are you asking for dialysis in a patient with a MELD this high who is not a candidate for transplant?" Dr. Z: "Yes, he's sick but the family is insistent." Dr. Y: "But in this patient it doesn't make any sense. I recommend you give another trial of albumin. Have you called palliative care?" Dr. Z: "We called you to do dialysis, not tell us how to manage our patient!" Dr. Z (after hanging up the phone): "How rude. Let's call another nephrologist." Dr. Y (after hanging up the phone): "Wow. He thinks we're just technicians." Introduction The request to initiate dialysis in critically ill patients with a very poor prognosis can create conflict between consulting physicians and nephrologists. Consulting physicians may think dialysis is a reasonable next step in critical care management, whereas nephrologists may worry that starting dialysis will unlikely add meaningful survival (1,2). It is not surprising that the discussion about the best course of action can lead to conflict. Conflict is widespread in health care settings, particularly when multiple clinicians are involved (3). Little guidance exists for how to navigate conflict between consulting and consultant physicians. Consultants adhere to an unwritten code of behavior in which their services depend upon the request of the consulting team and involve addressing a specific question or performing a relevant procedure (4). Tensions can mount when there is disagreement over the best plan of care. These conflict situations can fragment care and sever the relationship between consulting physician and consultant (5). Beyond the disagreement, conflict affects us on a deeper, more personal level. It affects how we view the consulting physician—"He just doesn't get it"; how we confront similar scenarios—"I'm just a technician"; and lastly how we see ourselves as physicians—"My opinion doesn't matter." These negative impressions contribute to burnout, low self-esteem, and increased turnover in the workplace (5,6). Drawing from our experience and literature on conflict mediation, we present three steps: (1) Pause and reflect on common pitfalls, (2) explore positions, and (3) develop a shared plan (Figure 1) (7,8). We will focus on the initial interaction where the conversation typically goes off the rails.Figure 1.: Three steps toward effective collaboration. Three steps for addressing conflict around dialysis decision-making.Pause and Reflect on Common Pitfalls Dr. Y's frustration with a request for dialysis in a patient with a dismal prognosis is understandable; however, the decision to call Dr. Z while still feeling upset likely planted the seeds for the ensuing conflict. These heated discussions tend to follow a familiar pattern. They become circular in that we mistakenly believe repetition will convince the other person to accept our message. Instead, each party feels ignored leading to surging emotions, raised voices, and ultimatums. A tell-tale sign of conflict is utterance of the word "but." The word "but" negates the previously stated position so that the listener only hears the second half—the speaker's position. The stronger one argues that his or her position is the right course of action, the more vigorous the counter response. Rather than rushing into the conversation, the first step calls for Dr. Y to pause before calling Dr. Z. When we take the time to acknowledge our own emotional response, we tend to calm down and are able to view the situation differently. Instead of adopting an "I'm right, you're wrong" attitude, constructive communication assumes both positions may be right. This means letting go of our own position to convince the medical team that dialysis is futile, and instead making room for theirs. An effective strategy for understanding the other person's position is to reflect on three common pitfalls that occur in conflict situations: factual disagreements, unacknowledged feelings, and negative effect on our identity as physicians (8). Figure 1 poses three questions to reflect upon these common pitfalls. The first pitfall is factual disagreements. That is, our facts may be different than those of the consulting physician. In this scenario, the nephrologist was anchored on the patient's poor prognosis as the reason to avoid dialysis whereas the intensivist focused on information from the family about the patient's preferences that might compel dialysis initiation—the patient's desire to live long enough for the birth of a grandchild and his willingness to undergo burdensome treatments to achieve this goal. By focusing only on Dr. Y's facts, which in this case were clinical data alone, she is less likely to seek Dr. X's information that supports a trial of dialysis. Another pitfall is unacknowledged emotions. Even when we try to suppress them, strong emotions tend to permeate conflict. The perceived "command" to perform dialysis triggered frustration in Dr. Y. These emotions can lead to a sense of helplessness and not having a genuine voice in the decision process—"If they ask for dialysis I guess I have no choice." Dr. Z. felt trapped, attempting to uphold the family's wishes. Considering the other person's emotional response may diffuse tension and allow for genuine empathy toward the challenging circumstance. The third pitfall is overlooking the effect conflict has on how we view ourselves personally and professionally. Dr. Y sees the request to start dialysis as threatening her self-perception as a competent consultant. This leads her to believe that she is instead a "technician." Likewise, Dr. Z's identity as an advocate for critically ill patients and their families is challenged by the outright resistance to his plan. Some conflicts may be "resolved" or better understood by reflecting on how the situation affects how we see ourselves. Explore Positions By reflecting on these common pitfalls, one is more likely to adopt a curiosity standpoint. This mental shift involves changing the question from "Why won't this person hear me?" to "I wonder why we see things differently." Being curious requires communication that encourages the other person's position. It is helpful to begin with a nonjudgmental invitation to learn the other person's facts. Phrases that assist with inquiry are prefacing questions with "Help me understand …" or "I'm curious about …" This exploratory language avoids attributing intentions to the other person and mitigates defensiveness. Open-ended questions often reduce tensions and allow the other person to share their position that may lead to a new understanding. Learning the other person's position requires us to listen. Becoming an active listener is fundamental to effective collaboration. Listening skills include using conversation continuers to acknowledge what the other person is saying and adopting open body language that conveys investment in what the other person has to say. When someone feels listened to, they are more likely to listen when it is our turn to speak. Strong emotions are at the core of difficult conversations. Simply stating "This is a tough case" demonstrates empathy to the challenging circumstances, helping to focus attention on the issue itself rather than on each other. How could this conversation have been different? Let's consider what would have happened if Dr. Y had paused before calling Dr. Z and reflected on the three common pitfalls: Dr. Y: "Dr. Z. Could you tell me about the patient?" Dr. Z: "This is a really sick patient. I am worried he won't survive this hospitalization. The family is asking for dialysis." Dr. Y: "I can see this is a tough situation." Dr. Z: "My hope is dialysis will provide time to see if he responds to antibiotics and allow the family to process the news that may be dying." Dr. Y: "Help me understand how dialysis will make a difference if he's not a transplant patient." Dr. Z: "The family is hoping the patient will live to see the birth of his first grandchild in a few months. He is willing to go through more treatments despite the slim chance of recovery." Dr. Y: "What I hear you saying is that despite his poor prognosis, the family feels he'd be willing to go through dialysis if there was a small chance of seeing his grandchild. Is that right?" Dr. Z: "That's right. I feel stuck. What are your thoughts?" Dr. Y: "I'm really worried this patient will suffer on dialysis. Can we outline a trial of dialysis that both acknowledges the family's hopefulness and addresses our concerns?" This conversation went much better when Dr. Y adopted a curiosity stance. Dr. Y learns different facts beyond the patient's poor prognosis. Using nonjudgmental, open-ended questions, she learns that the patient's goals support a trial of dialysis. By acknowledging that this is a tough case, Dr. Z feels validated and open to Dr. Y's concerns. Develop a Shared Plan Through a learning conversation, the nephrologist transformed what could have been a tense exchange into a collaborative opportunity to enhance patient-centered care. Ultimately, Drs. Y and Z worked together to develop a time-limited trial (TLT) of dialysis. TLTs are most effective when prognostic uncertainty exists or patient values support life-prolonging therapies. The steps of a TLT have been described (9). Successful TLTs involve frank conversations with patient and/or family about prognosis, defining what outcomes constitute that dialysis is helping and those that signal dialysis should be stopped, and a defined time to reassess whether clinical benchmarks have been reached. Clear communication positively affects the relationship between the nephrologist and intensivist, decreases the likelihood of conflict between family and medical team, and sets up timely opportunities for palliative care and quality end-of-life care (10). Conclusions We have discussed conflict that can arise when nephrologists are requested to perform dialysis in a patient who has a very poor prognosis. A stepwise framework and strategies that assist with approaching conflict have been elucidated. If adopted, there is a greater likelihood that a collaborative treatment plan, such as a trial of dialysis, will emerge from the conflict. In the process, professional relationships with consulting clinicians will also likely be strengthened. Disclosures None.