Sixteen residents of Intensive Care Medicine, Pediatric Intensive Care Medicine and Neonatology were interviewed, according to the semi-structured interview proposed in the study protocol. The interviews had a total of 170 minutes in the form of audios, which were transcribed for later analysis, with grouping of the main ideas exposed by the interviewees, these being the most prevalent ideas during the grouped analysis. After a thorough analysis, what we called the main clusters of ideas were selected.
1) Divergences regarding therapy / Definitions of care limitation and prioritization of comfort measures / palliative care.
Conflicts
and divergences in treatments such as those described by the participants are widely reported in the literature, which cites end-of-life decisions and communication problems as the main points related to divergences in the ICU (8) (9).
Conflicts
between members of the medical team are common in the daily practice of ICUs. In an article published by Azoulay at al. in 2009, 71.6% of participants reported having conflicts with team members (10).
There are several reasons for divergence between the ICU teams, as reported by the interviewees, among which end-of-life care stood out:
"So, usually what I see most in terms of disagreement between intensive care physicians on the ICU team and attending physicians is in relation to palliative care for a terminally ill patient, you know? Someone who already came with a terminal illness in all aspects and had an a complication in the ICU, their great difficulty in managing to evolve with palliative care...(E2)"
"Also patients with palliative (care), I think there is also this divergence that came to my mind now. The intensivist has a vision of limiting care, putting limits on the treatments, right?, and the assistant most of the time wants to extend (the care to the patient)(E3)."
"I remember a situation where palliative care was discussed for a 26-year-old patient admitted to the pediatric ICU and the team really wanted to introduce palliative care, and the assistant physician did not."(E12)
"They have great difficulty understanding that patients are sometimes terminally ill."(E13)
The introduction and definition of palliative care and prioritization of comfort is a frequent topic of debate in the medical field, with extensive literature related to the topic, most of which focus on ICU care (9)(10).
The admission of patients who are candidates for palliative care is seen by some as an event that should not occur, due to the aggressiveness of the treatments employed (going in the opposite direction of the "good death", without pain and close to the family), the costs related to health and the absence of clear benefits in terms of outcomes (11).
The exact timing for prioritizing comfort measures in detriment of therapeutic measures focused at healing is still a matter of conflict and bedside discussions. The withdrawal of life support measures is a common event in the intensive care unit, but it involves complex medical, legal and ethical aspects (12).
One of the reasons given by the study participants for this debate was the different relationship between the attending physician and the patient and his family, considering the stronger bond they have built over time.
"... most of the time they are patients from his office, where there is a personal, friendship closeness", "... there is a attending physician who, for example, has had a patient for 20 years in his office, has a different relationship with the patient and with the family, different from the intensivist..." "(E3)
"...it's the family doctor, it's the family pediatrician, someone recommended it to them..." (E11)
This point of view is shared by Angus and Truog (12), giving as an example that different team members may have different views regarding the patient's treatment and prognosis, for example an oncologist who dedicated months of treatment to a patient with little chance of survival.
"...the oncology team. They have a very big difficulty understanding that patients are sometimes terminally ill. And they want to do everything, and in fact they are causing more harm to the patient than actually doing other things..." (E13)
2) Ethical aspects related to the relationship with family members
Aspects related to the perception of patients and family members regarding the therapy and care in the ICU may be influencing factors regarding divergences in conduct.
In a survey carried out in several countries on points of view regarding end-of-life care, 50% of volunteers in Brazil, when asked “When it comes to assistance and care, what do you consider most important at the end of your own life?”, answered "prolong life as long as possible", data that differs from other parts of the world, Japan (9%), USA (19%), Italy (13%), where comfort and economic condition were considered more important at the end of life (13).
When asked about the relationship between physicians and family members and how much the family should be aware of divergences in conduct:
"...I think it has to be consulted, yes. I think it's a set, it's a decision..., because every procedure, any additional intervention, has its complications, it has its risks, so I think this has to be clearly explained, so that the family is aware (E3)".
"I think they have to know that they have options and that we are discussing the options. That something is not right. Not that we don't have to dichotomize relationships for the family... (E6)."
Based on this, we believe that whenever there are changes in care goals from healing to comfort, they must be carefully orchestrated and individualized according to the patient's needs, respecting ethical and legal aspects, according to Cook and Rocker (14).
In an article published by Molina RCM et al. in 2007 about the presence of family members in pediatric and neonatal ICUs, the view of the multidisciplinary team (doctors, nurses and technicians) is discussed on the positive and negative aspects of family presence and also the complexity of situations involving intensive care (15).
It must be considered that the presence of family members in the intensive care environment is increasing, which creates in the team the need to develop more effective communication (16). The model of physician care has also changed from a paternalistic model to a model of sharing decision-making, a fact observed by the interviewees in our study. “The divergences that I saw that happened, these more drastic ones are not such a common thing, not only the family were present, but the on call doctor, assistant physician, medical resident, intensivist, the coordination is called, there is not that double person debate and they try to enter into the best deal, we think that, in the end, we find the best deal, you know?
And “no, I'm against it, I'm right”, no, not that. (E11).
...the family's questions were for him and he was there willing to answer everything, really, any time of the day, any moment... So that made the team respect his opinion... because he had all this care for the family and the patient, in addition to the specialty. (E15)
The open ICU is already discussed more, soon the assistant physician, who already has a closer relationship with the family, also brings the family closer to the intensivist. ... Even if he is not very involved in the conduct of the ICU, he has, let's say, a “social relationship” with the family of bringing the family closer to the intensivist, I think there is this good part too. (E9)
The PARTNER study published in 2018 by White, D.C. et al. (17) compared offering multidisciplinary family support with usual ICU care. His intervention included several family meetings, with the concern of getting to know the patient and the family as individuals, ensuring that treatment options were discussed, ensuring that the care plan was clear to the family. These interventions, considered low cost and simple to perform, were enough for family members to better classify the quality of communication and a shorter length of stay in the intensive care unit was also observed.
Difference between the attending team and ICU team
In consultation with CREMESP, opinion No. 141.403/08, it is argued that the intensive care physician may, after discussion with the attending physician in cases where there is no urgency, indicate diagnostic and therapeutic measures. In this opinion it is clear that the responsibility while the patient is in the ICU lies with the physician intensivist (18).
When asked about how the on call physician acts in the face of divergences in conduct with the attending physician:
of not wanting to have a conflict with an attending physician, sometimes that attending physician has some position in the institution, you don't want to have a conflict with him, you think that the attending physician may have the impression that you want to conduct his case, to interfere in his case. I think there are on-call doctors who do not want to have this conflict. (E3)
So sometimes there is some conduct that the intensivist even thinks is not the most appropriate, but he also ends up judging something that will not bring harm to the patient, he ends up accepting the conduct of the attending physician... just to avoid conflicts. (E1)