Conflict in intensive care units: a conceptual framework for patient, family, team, and inter-service disagreement
9 affiliations
- 1Department of Anesthesiology, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, 30322 GA USA
- 2Emory Critical Care Center, Atlanta, GA USA
- 3Department of Critical Care, University College London Hospitals NHS Foundation Trust, London, UK
- 4Department of Targeted Intervention, University College London, London, UK
- 5Department of Intensive Care Medicine, Ghent University Hospital, and Faculty of Medicine and Health Care Sciences, Ghent, Belgium
- 6Famiréa Research Group, Medical Intensive Care Unit, Assistance Publique–Hôpitaux de Paris, Saint Louis University Hospital, Paris, France
- 7INSERM UMR 1342, Institut de Recherche Saint-Louis, Paris, France
- 8Department of Critical Care, King’s College Hospital NHS Foundation Trust, London, UK
- 9Honorary Reader, King’s College London, London, UK
Abstract
For clinicians, conflict in the intensive care unit (ICU) is both common and expected owing to the nature of critical illness and its treatment. Examination of conflict in this context has been conceptually diffuse. Studies of moral distress, psychological safety, ethical climate, and other fields offer valuable insights that can be challenging to synthesize cohesively, due to differences in concepts, methods, and disciplinary perspectives. This narrative review integrates this literature using a task-process-relationship framework from organizational psychology. Conflict in the ICU arises in two principal arenas: between clinical teams and patients, families, or surrogates, and within and across clinical teams. Patients who retain decision-making capacity are a distinct and often overlooked party to conflict, as the focus has primarily been on the families and surrogates who speak for those who cannot. The task-process-relationship framework suggests a recurring escalation pattern for both arenas. Genuine task disagreements about treatment, prognosis, or goals of care can become destructive in the presence of process gaps or failures. These include role ambiguity, inconsistent messaging, and perceived unfairness. From there, conflict can enter the relationship domain wherein mistrust or identity threat makes resolution far harder, and two implications follow. First, much of what clinicians may describe as a “difficult family” can often be a response to antecedent process failures rather than a purely interpersonal problem, emphasizing the importance of engineering robust processes and systems in the ICU to avoid conflict reaching the relationship domain. Second, family and team conflict are linked in that unresolved team disagreement can reach families as contradictory recommendations and mixed messaging. Challenging family situations can expose team misalignment and damage collegial relationships. Evidence-based interventions, organized by conflict type and escalation stage, suggest that the most promising investments are structural, namely those built into rounds, improving role clarity, ensuring pre-conference team alignment, and fostering ethical climate. When conflict becomes entrenched, formal supports such as mediation and ethics consultation are matched to the nature of the dispute. While disagreement in intensive care is inevitable, destructive conflict is not.
Graphical abstract:
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BibTeX
@article{jabaley2026conflict,
title = {{Conflict in intensive care units: a conceptual framework for patient, family, team, and inter-service disagreement}},
author = {Craig S. Jabaley and Zoe Brummell and Dominique D. Benoit and Nancy Kentish-Barnes and Victoria Metaxa},
journal = {Critical Care},
year = {2026},
month = aug,
doi = {10.1186/s13054-026-06248-7},
url = {https://doi.org/10.1186/s13054-026-06248-7},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Conflict in intensive care units: a conceptual framework for patient, family, team, and inter-service disagreement
AU - Craig S. Jabaley
AU - Zoe Brummell
AU - Dominique D. Benoit
AU - Nancy Kentish-Barnes
AU - Victoria Metaxa
PY - 2026
DA - 2026/08/15
JO - Critical Care
DO - 10.1186/s13054-026-06248-7
UR - https://doi.org/10.1186/s13054-026-06248-7
AB - For clinicians, conflict in the intensive care unit (ICU) is both common and expected owing to the nature of critical illness and its treatment. Examination of conflict in this context has been conceptually diffuse. Studies of moral distress, psychological safety, ethical climate, and other fields offer valuable insights that can be challenging to synthesize cohesively, due to differences in concepts, methods, and disciplinary perspectives. This narrative review integrates this literature using a task-process-relationship framework from organizational psychology. Conflict in the ICU arises in two principal arenas: between clinical teams and patients, families, or surrogates, and within and across clinical teams. Patients who retain decision-making capacity are a distinct and often overlooked party to conflict, as the focus has primarily been on the families and surrogates who speak for those who cannot. The task-process-relationship framework suggests a recurring escalation pattern for both arenas. Genuine task disagreements about treatment, prognosis, or goals of care can become destructive in the presence of process gaps or failures. These include role ambiguity, inconsistent messaging, and perceived unfairness. From there, conflict can enter the relationship domain wherein mistrust or identity threat makes resolution far harder, and two implications follow. First, much of what clinicians may describe as a “difficult family” can often be a response to antecedent process failures rather than a purely interpersonal problem, emphasizing the importance of engineering robust processes and systems in the ICU to avoid conflict reaching the relationship domain. Second, family and team conflict are linked in that unresolved team disagreement can reach families as contradictory recommendations and mixed messaging. Challenging family situations can expose team misalignment and damage collegial relationships. Evidence-based interventions, organized by conflict type and escalation stage, suggest that the most promising investments are structural, namely those built into rounds, improving role clarity, ensuring pre-conference team alignment, and fostering ethical climate. When conflict becomes entrenched, formal supports such as mediation and ethics consultation are matched to the nature of the dispute. While disagreement in intensive care is inevitable, destructive conflict is not. Graphical abstract:
SN - 1364-8535
SN - 1466-609X
ER -