Conflict Resolution in the Intensive Care Unit for Incapacitated Adults

: How should disagreements between patient representatives and healthcare professionals, around the best interests of the incapacitated adult patient, be managed in the intensive care unit?

Abstract

This thesis explores how disagreements over the ‘best interests’ of incapacitated adult patients should be managed in intensive care units (ICUs), integrating medico-legal, ethical, and empirical perspectives to propose practical recommendations. Employing an empirical bioethics approach, the research combines a narrative review, a systematic review, a qualitative study, and normative analysis using a process of ‘reflective equilibrium’.
Existing literature recognises the sequential and relational dimensions of best interests disagreements. Several mechanisms for resolving best interests disagreements exist, yet they are variably implemented in clinical practice. Having identified that most conflicts are addressed internally, I conducted a systematic review focusing more specifically on how physicians address conflicts in end-of-life decision-making. This review identifies strategies tailored to the conflict’s nature, but these often rely on using processes of reasoning and rationality as a response to deeply emotional conflicts.
The qualitative research then involved reflexive thematic analysis of semi-structured interviews with 41 participants, including professionals, former patients, and their representatives, recruited from six ICUs in England. Using the method of ‘reflective equilibrium’, I produce normative recommendations for managing best interests disagreements, by synthesising my own moral intuitions, theoretical insights, and the empirical findings.
A key finding is that while disagreements are, to an extent, inevitable in ICU settings, their escalation can often be mitigated. Professionals frequently rely on rational approaches when communicating, which involve providing information and constructing logical narratives of the patient’s likely trajectory. Yet these approaches do not adequately address the emotional and relational complexities of conflicts. The thesis advocates for integrating non-rational, dialogical approaches into ICU communication strategies, to foster mutual understanding and trust. Additional recommendations focus on addressing power imbalances within internal and external mechanisms for resolving disagreements. I conclude that communication grounded in mutual understanding, empathy, and bidirectional dialogue is not supererogatory – it is an ethical imperative.

Date of Award	13 May 2025
Original language	English
Awarding Institution	University of Bristol
Supervisor	Giles M Birchley (Supervisor) & Richard Huxtable (Supervisor)