Transcript
Speaker: Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: And now, your host, Dr. Sergio Zanotti.
Speaker: Welcome to another episode of Critical Matters.
Speaker: Today we'll be discussing the practice of respect in the ICU.
Speaker: It is a great honor and pleasure to have Dr. Samuel Brown as our guest.
Speaker: Dr. Brown is the director at the Center for Humanizing Critical Care and Intermountain Medical Center.
Speaker: He's a practicing intensivist and holds an appointment as associate professor of medicine at the University of Utah School of Medicine in Murray, Utah.
Speaker: Dr. Brown is an NIH-funded researcher with an interest in the body's response to critical illness, non-linear hemodynamics, and echocardiography.
Speaker: He has published extensively in these topics and also in the intersection of critical care, ethics, and history.
Speaker: Dr. Brown is also a respected medical humanist and ethicist with a special interest in embodiment, sickness, and the end of life.
Speaker: Dr. Brown has authored a book entitled Through the Valley of Shadows, which covers many of these topics.
Speaker: He is the lead author in a recently published paper in the Blue Journal, The Practice of Respect in the Intensive Care Unit.
Speaker: Dr. Brown, welcome to Critical Matters.
Speaker: Thanks so much, Sergio.
Speaker: It's a pleasure to be with you.
Speaker: I think it would be great to just acknowledge that respect and dignity are values that intuitively we would accept as important and necessary in our critical care practices.
Speaker: However, I feel and suspect many of our listeners would agree that these values may be actually lacking in the ICU today.
Speaker: So why don't we start by defining these terms?
Speaker: How do you think about respect and dignity?
Speaker: That's a great question.
Speaker: You know, we had a much longer version of the
Speaker: of the perspective piece originally where we walked through the origin of these terms and a lot of the professional readers, the reviewers felt like we went into too much detail, but I think they're interesting stories.
Speaker: The basic notion behind dignity is that dignity historically meant a special kind of human being.
Speaker: It meant the aristocracy, the queens and the kings and the ruling class
Speaker: And dignity was a mark of superiority of particular individuals.
Speaker: And then in the 18th century, you know, it starts a little earlier and then extends dramatically along over the next two centuries.
Speaker: There's this notion that maybe dignity belongs to every human being.
Speaker: Maybe we've misunderstood that.
Speaker: And the part that makes you worthy, you know, dignity comes from
Speaker: being dignified, it comes from being worthy of something, meriting something.
Speaker: Maybe you get there just by token of being a human being.
Speaker: Maybe you don't actually have to be the king to be dignified or worthy of some response.
Speaker: And we made the argument that respect, and this is an argument that comes out of the Quality and Safety Group at Beth Israel Deaconess, who have been real pioneers here and are part of this overall project,
Speaker: They said, you know, at a practical level, why don't we say that respect, which comes from an old group that means to look again, what if respect really refers to the practices or behaviors that acknowledge the inherent dignity of other human beings?
Speaker: And so for us, this really became a story of respect and dignity as interrelated terms, but dignity is something that every human has just by token of being a human and respect to the practices and behaviors that honor it.
Speaker: And one way to think about the etymologies is to think that
Speaker: Respect and dignity are fundamentally about acknowledging that people are worth seeing Respect to look again dignity having merit or worth so we think of it as people are worth seeing in the ICU That's how I think about those two terms and I think that it's a great it's a great definition explanation because they are different concepts but
Speaker: they go hip by hip together and they can't probably coexist one without the other one, especially in the world of critical care.
Speaker: One of the things that I think makes me think about this concept, Sam, is Henry Thoreau said that every man is my master, alluding that every human being we meet knows something that we don't know or can teach us something we don't know.
Speaker: And from that perspective, everybody we meet, whether it be a patient or a
Speaker: another provider in the ICU can teach us something and definitely deserve all our respect from that perspective.
Speaker: John Thoreau and the other transcendentalists were a big part of that movement I was talking about to say that dignity is not just for the queens, kings, and presidents.
Speaker: So it's an inherent condition to being human.
Speaker: And I think that that's something that we often forget in the ICU, not only with our patients but with our coworkers.
Speaker: And we'll get to that, I think, a little bit later.
Speaker: Let me ask you, how does compassion fit into this?
Speaker: Could you be compassionate and be without having respect for your patients?
Speaker: Or visa versa?
Speaker: Yeah, we had a big expert convening meeting that was the genesis for this piece we did for the Blue Journal.
Speaker: And as we got together, we started running through the list of the kinds of positive adjectives you might apply to a person that seems...
Speaker: deeply humane or aware of the big issues.
Speaker: And one by one, they all, if you didn't attend very closely, they all sort of started to run together.
Speaker: So compassion as we think about it as the capacity or desire or the manifestation of a
Speaker: a sense of shared identity that tinges oneself with sadness when another person is sad.
Speaker: And in that respect, it's not so different from empathy.
Speaker: And I think we get at the, we're getting at the same thing.
Speaker: We're getting at a notion that when we encounter another human being, we make ourselves open to the miraculous beauty of humanity as manifested through this
Speaker: specific individual and I think compassion if you have true compassion I think you are likely to be respectful that said I think there are times that you can you can practice respect and not be overwhelmed by compassion there plenty of casual encounters that we have with people that don't require a deep emotional resonance but nevertheless do require a respectful
Speaker: So one of the reasons in our practical work we've been focusing more on respect and dignity is that those are a kind of baseline behavior set that can be done regardless of the emotional state of the given clinician and that don't require the kind of intense, continual emotional investment in patients that so rapidly can lead to compassion fatigue.
Speaker: We in the ICU and our colleagues in oncology and advanced heart failure and other domains who care for people at high risk for death, we have to have a capacity to continue to care for these people both medically and humanly.
Speaker: And if we had perfect, infinite, exquisite compassion such that every death of every patient we encountered affected us the same way that the death of an intimate
Speaker: relative would affect us, we'd all lose our capacity to come to work.
Speaker: We'd be so hopelessly bereaved we couldn't get out of bed in the morning.
Speaker: So what we're trying to get at with respect and dignity is a notion that we can honor and acknowledge the marvelous beauty and power of every human being in our encounters with them in a way that on average is
Speaker: possible for clinicians who care for patients at high risk for pain and death.
Speaker: And I'm a strong believer in compassion.
Speaker: And I think even as we're navigating the stresses of caring for patients who are at high risk for death, we don't want to cut ourselves off from compassion, even as we want to be careful and aware that we ourselves only have a certain amount of emotional
Speaker: That's sort of a long answer to the question.
Speaker: But when we talk about respect and dignity, not uncommonly we do hear from clinicians who are really worried about their discapacity to go about their lives if every death of every patient is experienced as the kind of tragedy that it truly is to the person and the people that love them most.
Speaker: So we're trying to help people understand that what we're after is a balance,
Speaker: and an awareness of the intrinsic dignity of every person and a greater sort of pushing the needle as we say in the modern jargon a little bit closer or maybe quite a bit closer to that model where we are respectful of each other in a way that encourage all of us to flourish as human beings and i think that that i mean that's a great way of looking at it because
Speaker: in late language when we talk about this I think without a lot of thought, these
Speaker: terms seem to be used interchangeable and people refer to the same concept.
Speaker: I think like you said, there are different layers and have different implications also for the provider.
Speaker: So I think that really thinking of dignity and respect as the building stones to really a more humane practice for our patients, but also for the providers.
Speaker: One of the things that I really liked from the Blue Journal paper was one of the tables that talked about
Speaker: Specific examples of respectful and disrespectful behavior because I think at the end of the day Defining terms talking about what it means is only important to the extent that we can recognize that
Speaker: how we're doing it or when it happens around us.
Speaker: Do you mind, Sam, if we just go through some of these common encounters that occur in the ICU on a daily basis, and you can maybe show us or comment on a disrespectful approach that is probably very common and how you would think would be a more respectful approach to take it.
Speaker: So I guess the first thing that happens every day when I walk into the ICU and start seeing my patients is I approach a patient's bed or enter a patient's room.
Speaker: Yeah, I think the thing that, you know, these patient family advisory councils that are showing up at more and more hospitals, and I think should, they're a marvelous thing.
Speaker: We've run one for several years, and the group at Beth Israel Deaconess, which again is a pioneering group here, have one for, I think, a decade now.
Speaker: You really, you sort of sit down together as peers and you think through that process of the encounters and the experience.
Speaker: and you learn some dramatic things.
Speaker: And one thing that I learned from a patient family advisor as we were talking about this question of entering a room was that when you're a patient in the ICU, that room is your home.
Speaker: More to the point, that room is really your bedroom.
Speaker: And it's experienced as a private place.
Speaker: Now, we
Speaker: Clinicians don't think that way.
Speaker: We clinicians just see it as the place where the current patient is being housed.
Speaker: Their home is off in another city somewhere, and we would never go into that home uninvited.
Speaker: But when we come to the room, we clinicians think of ourselves as owning the room and almost as if the patient is squatting there in our home.
Speaker: The reality is the patient experiences it as their bedroom.
Speaker: And I think once I understood that, I thought, oh, crap.
Speaker: because we all do things that are less than what we wish we were doing, and that's true of all of us, even those of us that are agitating for change.
Speaker: I realized, oh man, I wouldn't walk into a person's home without knocking on the door.
Speaker: I mean, so why am I doing it routinely in the ICU?
Speaker: And so after that, patient family advisor revealed, the story was that she was asleep in bed
Speaker: And somebody walked silently into a room and touched her.
Speaker: And everybody thinks it was probably a phlebotomist drawing morning labs and tried to sneak into the room unannounced so as to let her sleep, maybe draw the blood off the art line, and she'd sleep through the whole thing.
Speaker: But she woke with a start in her own bed to a stranger standing over her.
Speaker: And that image just haunted me.
Speaker: I thought, oh,
Speaker: You know, think about us at home in our own bed awake suddenly to a stranger staring at us.
Speaker: That was very unsettling to me.
Speaker: So ever since then, I knock.
Speaker: When I go to a room, I just knock.
Speaker: And, you know, 10% of the time when I knock, it's actually not an opportune moment.
Speaker: They're in the course of being bathed or they're on the toilet or there's some other reason that they don't want a visitor.
Speaker: And so that's helpful information to me.
Speaker: I knock, they say not ready, and I step back and I go back.
Speaker: I go to another room and I circle back.
Speaker: And that's another component of dignity.
Speaker: If we believe a person has dignity, then that has to involve some sense of privacy and or control over their body, admitting that in the ICU commonly the normal modes of interacting around bodies are affected in some important ways.
Speaker: And some are necessary, right?
Speaker: I mean, all of the life support stuff that we do violates the integrity of a body.
Speaker: So it's not as simple as just the normal social encounters we'd have.
Speaker: But even within the strange setting of the ICU, I think, as you've indicated, there are still gentle things we can do.
Speaker: And so for me, I don't enter rooms in the ICU anymore without knocking.
Speaker: It takes a second and clearly communicates respect.
Speaker: And I think that the way you framed it is very powerful, but I also think another way of thinking about this is that we talk a lot about patient-centered care, yet everything we do centers around our needs and our convenience.
Speaker: When we see the patients, how we round, how we organize this, how we organize that, and I think that
Speaker: moving forward that definitely needs to change.
Speaker: So one of the things that we, of course, very commonly in the ICU is that our patients are intubated, sedated, hopefully less and less, but really or might be unconscious.
Speaker: How about when we approach that patient and start to examine them?
Speaker: Could you talk about respectful, disrespectful behaviors in that action?
Speaker: Yeah, this observation came up when we were doing a project here at Intermountain trying to understand what made a great nurse from a patient's perspective.
Speaker: And so we went through the unsolicited feedback cards that came in, and we found that essentially every patient praise for a nurse, you know, the spontaneous praise that comes from the families written to the nurse manager or the hospital CEO, essentially every one of the nurses identified in that way.
Speaker: the family said, he spoke to my loved one or she spoke to my loved one even when they were asleep as if they could hear or as if they were a person.
Speaker: And that was sort of disconcerting to me because I'd never done that.
Speaker: I just assumed if you're unconscious, whatever you're unconscious, I don't need to talk to you other than to say, open your eyes to see whether you're in a coma.
Speaker: But realizing that the families experienced it that way made me pause a little bit and wonder what I was doing.
Speaker: And then the other observation is
Speaker: this growing awareness of two phenomena.
Speaker: One is that patients in this state are integrating stimuli from the environment into delusions, nightmares, and dreams that they're having.
Speaker: And so there's some sense in which our interactions with apparently comatose individuals are remembered in distorted ways.
Speaker: So it's important to make them as much as we can within medical necessity, non-toxic,
Speaker: And then the second piece is increasingly realizing that some people actually can hear, and we don't know precisely when they recover the ability to hear clearly.
Speaker: And so in those circumstances, it's important to talk.
Speaker: So the way we do it now, or the way that I do it and that we recommend and recommend in the paper is with a comatose individual, you address them and you tell them you're about to touch their body.
Speaker: Just, you know, we use a thing, I can't remember whether we called it that in the Blue Journal thing,
Speaker: we use a thing we call the dinner party rule.
Speaker: And basically the dinner party rule says imagine that you've been invited to a dinner party by a host that you respect.
Speaker: Now ask yourself, when you're about to do a behavior in the intensive care unit, is this something I would do to the host of a dinner party?
Speaker: You wouldn't enter the house without knocking.
Speaker: You would address them by their preferred name, not by some name that you found off a birth certificate or some official registration document.
Speaker: And you would
Speaker: give them some indication, ideally asking permission, before you touch their body in any way.
Speaker: That's just a normal part of the way human beings interact.
Speaker: So the way we recommend interacting with comatose individuals is just to say, hi, use the preferred name that you've identified from the family, or if not that, then you know it's Ms.
Speaker: Jones.
Speaker: I'm Dr. Brown.
Speaker: I'm the supervisor for the doctors.
Speaker: I'll be examining you now.
Speaker: I need to examine your leg or I need to examine your genitalia or whatever it is.
Speaker: Just giving them some sense if they're listening and in any case reminding yourself that this is a human being and the way you interact with human beings follows more or less that dinner party rule that I talked about.
Speaker: You indicate before you touch.
Speaker: And that notion of touching also was triggered for me by this.
Speaker: I was rounding
Speaker: At night, I was covering for night, wasn't the day attending.
Speaker: And we came to a patient, diabetic in septic shock.
Speaker: The team told me they didn't know the cause.
Speaker: And I said, well, have you thought about Fournier's?
Speaker: And immediately, the resident, without drawing the drapes closed, without telling the patient, without any other indication of what was going on, had grabbed the man by the scrotum and elevated his genitalia.
Speaker: And it just, that image just struck me so vividly that this man had noiselessly with no introduction or warning and no privacy in full display to everyone in the ICU grabbed another man by the testicles.
Speaker: And that struck me as wrong.
Speaker: And so that's when we have to examine now, even if they're comatose, we say, hi, I'm sorry, I need to examine your genitalia.
Speaker: And I think that's a good practice to remind
Speaker: people of respectful behaviors toward the body of another person.
Speaker: And I think that those are all great points.
Speaker: And I'm actually very happy that there's some validation to something I've been doing for a long time, but without thinking about in this terms, when families would ask about comatose patients, should we talk to them?
Speaker: I've always said, well, you should talk to them, assuming that they can hear you.
Speaker: It's important for them probably to know that you're here.
Speaker: But even though I think we're good at giving people advice, we're not as good as following that advice ourselves.
Speaker: And maybe I've examined that patient that morning without talking to them and letting them know what I was going to do.
Speaker: So I think a very powerful
Speaker: lesson for everybody.
Speaker: What about rounds?
Speaker: Rounds are an intricate part of the ICU.
Speaker: I think it's one of the things that defines us, our multidisciplinary approach.
Speaker: More and more at our ICUs and sound critical care, we are really trying to make a deliberate effort and designed to include families.
Speaker: How do you view the presence of families or patients in rounds?
Speaker: I think that, to be honest, we can no longer provide any credible rationale for excluding families from rounds.
Speaker: We started this in earnest probably four years ago, and now it's a routine open invitation.
Speaker: Families are always invited to rounds.
Speaker: And when we first started doing it, it was a little bit, we had to kind of figure out, work out the kinks, just how precisely do you interact with the family members during rounds.
Speaker: And for us, the family members are invited to all of rounds, not just at the end to say, hey, this is what we decided, what are you thinking?
Speaker: We bring them into rounds.
Speaker: Now, it's been our experience that probably only about 30% of families actually want and are able to be on rounds.
Speaker: But what's crucial is the open invitation, because when you invite them to participate, they know that you actually honor them as members of the team.
Speaker: So my usual statement to people is, you're as much a member of the team as we are.
Speaker: I mean, we need you as much as you need us.
Speaker: So they come.
Speaker: And it's been our experience that 90 plus percent are just glad to be a part of it.
Speaker: The first several times they go, they don't understand a word anybody's saying.
Speaker: And then they start to get a little more confident and then they'll ask a little question.
Speaker: I find very commonly that they know more about the patient's course than the current bedside nurse, definitely more about the patient's course than the house staff.
Speaker: And so it's very common that we actually get a net benefit purely on a medical clinical side from having the family members in rounds.
Speaker: And then of course the human side is substantial.
Speaker: You know, I found back,
Speaker: before we used to have families on rounds and present during procedures and total elimination of visiting hours, I found that as an attending, you know, it seemed like 30% of my job was what I called apology rounds, where I would just go around from like four o'clock until six o'clock p.m.
Speaker: apologizing to families that they didn't feel like they'd had enough attention through the day.
Speaker: They didn't feel like they understood what was going on.
Speaker: They didn't feel like they were getting the, the, the,
Speaker: focus of resources that he felt they deserved and commonly had no idea that we had spent 45 sustained minutes deliberating carefully about how we were going to proceed and what needed to happen, et cetera.
Speaker: All they knew was that they'd seen us for 60 seconds and had some quality time with the nurse.
Speaker: So what I found now that we've more fully integrated family members into the flow is that I don't have to do apology rounds.
Speaker: upset families have become the exception rather than, you know, sort of the norm, because they're with us when we're doing this stuff.
Speaker: I've even started when I got to do some follow-up on the labs, I just wander into the patient's room and check the labs there.
Speaker: I got to check the labs anyway.
Speaker: Why shouldn't I do it in the presence of the patient and family?
Speaker: And then they can see that we're doing it, and I'll, you know, let them look over my shoulder as we look at the labs.
Speaker: And it's been really a good
Speaker: I think when we first started, we were a little bit worried about the time commitments and whether there would be weird dynamics.
Speaker: And occasionally, you do have to, if you've got an intern that's especially eager to talk about end of life, but they haven't figured out how to communicate with the family, you have to sort of teach them in the presence of the families.
Speaker: You don't say your weird, categorical, harsh statements about life and death issues.
Speaker: But that doesn't mean that you can't have these important conversations even in rounds.
Speaker: You learn a more respectful language to do it.
Speaker: So we're huge fans at Intermountain of family-based rounding.
Speaker: The thing to note about us is that we, because we were one of the early places to be computerized back in the 70s and did a lot of physiology and information systems and have large multidisciplinary, we actually have a rounds room where we do the rounds.
Speaker: So the family member comes with the nurse when the nurse comes to rounds.
Speaker: In institutions where rounding is true bedside rounding, that's even easier to get the families involved.
Speaker: They just step out the door to the team that's standing in the hallway and participate.
Speaker: So both of those models have been able to work in our experience.
Speaker: And in most of our programs, we don't have trainees, and some we do, but most we don't.
Speaker: So we usually do bedside rounds, and the families are part of it.
Speaker: And we have also found that it's transformational in terms of, like you said, saving time for us later, but also in terms of how they feel integrated.
Speaker: And they are also experts.
Speaker: They're experts in the human beings in that bed, and they have that expertise that we don't have, and I think it adds a lot.
Speaker: what about i call them the world experts in the humanity of the patient exactly are and they are they know things that we would never know what about highly charged situations like a cardiac arrest i think that when i was a trainee it was like a absolute no no family members during a cardiac arrest and probably because we know how we behave during these situations but now it's changed and
Speaker: As we try to do this better, what would be examples of disrespectful and respectful behaviors in that situation, Dr. Brown?
Speaker: I think that's a great point.
Speaker: There are a couple of RCTs.
Speaker: I know some people like to argue about the outcome of the RCTs, but I think, just being totally honest, there are reasonable RCTs, and the reasonable inference from those RCTs is that families should be invited to be present for CPR.
Speaker: And to be honest, we've extended that well beyond CPR, and in the white journal, Annals of ATS may be,
Speaker: two years ago now, a junior faculty who's great, Sarah Beasley, and is really a rising star in this area, led an effort to describe our experience of family procedural presence for all of the procedures that we do in the ICU.
Speaker: And again, it takes a little bit of training.
Speaker: You get a little bit used to it.
Speaker: I found that it's much easier to do procedures in the presence of families, to learn that skill
Speaker: than it is to learn how to train an NP or an intern or a resident doing the procedures.
Speaker: So after just a few procedures, you get pretty accustomed to doing the procedures with the families right there.
Speaker: You screen them for fainting risk, and you make sure if they're intoxicated or wild, they're not allowed to stay.
Speaker: I mean, safety first, absolutely.
Speaker: But then you find that it's very easy to integrate them in, and that humanizes in a couple of ways.
Speaker: It's just, it's, you know, nothing about me without me.
Speaker: That's the classic disability rights phrase, and I think it applies in the ICU.
Speaker: If something's happening to their loved one, they want to be there.
Speaker: Why would they be exiled from the side of their beloved at their time of greatest need?
Speaker: It just makes no sense at all.
Speaker: The second thing that I find is that, like you said, we behave a little better.
Speaker: We're less disrespectful.
Speaker: I think particularly when we get tired, we can do things that frankly would embarrass us if we could see them when we were
Speaker: well rested and looking in from the outside.
Speaker: And so having the family members there I think helps us to do healthier and more respectful ways of dealing with the stress.
Speaker: And again, I think it's just part of this broader sense of teamwork that we have together.
Speaker: So when I run a code and family members there, I'll usually bring the family member to my side.
Speaker: I'll put my arm around their shoulder.
Speaker: I'll have the family member put their hand on the foot of the patient so that there's some skin contact.
Speaker: That keeps us out of the way of the people doing the CPR and the other procedures, allows us to see what's going on, and then I'll run the code with them right there.
Speaker: And if they, it's been my experience that just having me right next to them knowing that they're with the person that's in charge is enough, and we have not had difficulties with them
Speaker: the worry is always, oh, they're gonna interfere with the CPR, they're not gonna make it work, et cetera.
Speaker: But they've been great about it.
Speaker: And I think it also can be, when it's appropriate, a natural way to make the transition to recognizing that the CPR didn't work.
Speaker: And then, a lot of what happens when a death, an undesired death happens
Speaker: is the grief, and there's no way around the grief.
Speaker: It's just sad when people die.
Speaker: It just is.
Speaker: But there's also a component of wanting to make sure that death has been resisted in a meaningful way, that there's been no abandonment, that there's been no hunger for the person to be dead, and often allowing people to be present for the CPR takes care of that component of the grief.
Speaker: They know that we really did try.
Speaker: They saw us trying to circulate the blood with our own hands.
Speaker: in the patient's body.
Speaker: And I've found that in my personal experience, the somewhat tentative observations from the randomized control trials suggest that, in fact, they do better knowing that this has been attempted.
Speaker: It's the closure.
Speaker: I mean, understanding, and I think it's also, this is also true for rounds in terms of understanding how many
Speaker: different disciplines and how many people are interested in their loved one getting home.
Speaker: There's nurses, there's specialty therapists, there's nutrition, there's chaplains.
Speaker: And I think that when they see that, regardless of the outcome, I think that they feel a lot better about what has been done for their loved ones.
Speaker: So these are all very, very important lessons.
Speaker: The last behavior that I think is very relevant for our audience since I presume we have a lot of young listeners has to do with attention.
Speaker: our attention during any encounter with families and patients.
Speaker: And this is something that I'm sure a lot of us struggle with socially as well when we're out to dinner with friends, when we're at home.
Speaker: But you want to maybe talk about this a little bit?
Speaker: Yeah, we all struggle with this now.
Speaker: We've become addicted to the virtual encounter with the world.
Speaker: people can tell when you're paying attention to them and they can tell in a high-stakes moment if you're disengaged that you don't respect them so when you're at the bedside you really ought to have your attention with them at the bedside and if there is an occasional moment where you cannot for a compelling clinical reason you identify that fact explicitly you just say I
Speaker: I'm sorry, there's an emergency I need to address, or I'm sorry, I need to see what this page says.
Speaker: Because when you indicate it, and when you indicate it with an apology that indicates that it's a deviation from what's expected, you do them the respect of anticipating that they have some claim on your attention.
Speaker: When you just do it, when you just divert your attention without signaling that you're doing it explicitly, you're telling them that they're not even worth the
Speaker: updating to know that something has happened.
Speaker: And often you do have to look at a computer during an encounter with a patient.
Speaker: And my goal with that has been to show them what you're looking at so that your attention can be shared with this other thing.
Speaker: But I think, you know, it's hard to be a clinician these days.
Speaker: It's exhausting and stretching.
Speaker: And there's a strong temptation to divert yourself to other attentional tasks while a patient or family is
Speaker: telling a story that's not immediately relevant to the medical aspects of their care.
Speaker: But I think we have to acknowledge that it's disrespectful and it makes us mad when our teenagers do it to us as parents and our patients and families have every right to be upset if we're allowing ourselves to be distracted during our encounter with them.
Speaker: And I think it's one of those things that we just have to recognize and make a deliberate effort.
Speaker: And it's really about becoming better listeners, right?
Speaker: And if we just learn to listen, to truly listen, I think a lot of this would be taken care of.
Speaker: Do you think of disrespect to a patient in the ICU as causing a harm to that patient?
Speaker: And how do you think about that?
Speaker: We debated that question for a long time, both in the expert consensus conference and in the writing of that piece for Blue Journal.
Speaker: Historically, we've tended to say, if something causes a quote unquote objective harm, then we care about it.
Speaker: If it led to an adverse drug event, if it led to a hospital fall with a broken hip, if it led to a readmission, then something is bad.
Speaker: And we've been very much driven by the secondary effects of certain kinds of behaviors.
Speaker: And at some level, we need to be mindful of the secondary effects of the things that we do.
Speaker: We weren't advocating that you ignore secondary effects, but we wondered together whether disrespect itself, particularly when it was in a severe kind of mode,
Speaker: was sufficient to represent a harm in and of itself.
Speaker: In other words, even if there were no other secondary harm related to it, it could be considered a harm in its own right.
Speaker: And that basically is saying that disrespect is intrinsically bad.
Speaker: Now, as it turns out, it turns out that there's some interesting evidence, mostly from simulation studies, but not exclusively from that,
Speaker: that certain models of disrespect palpably lead to what we've traditionally called objective harms.
Speaker: And so there's also that reason that we should be attending to it.
Speaker: But we've argued that profound, profound disrespect really ought to be considered a harm in and of itself.
Speaker: And again, that group at Beth Israel Deaconess in Boston have already integrated into their
Speaker: quality and safety work a disrespect dashboard.
Speaker: And that disrespect dashboard treats them the way any other adverse event was, is treated.
Speaker: Now, that's not, they don't investigate every single time someone forgets to knock before they enter a room.
Speaker: But for example, when the hospital lost the body of a patient, that was a grave disrespect.
Speaker: You know, nobody died early as a result of it.
Speaker: There were no, I mean, the patient was already dead.
Speaker: but losing the body through a miscommunication in the morgue and the funeral home, that's profoundly disrespectful.
Speaker: So they investigated it with a root cause analysis as an adverse event in its own right.
Speaker: And I think that the direction that BID can as people have taken in that regard is in fact, it's right headed.
Speaker: Clearly not every disrespectful event will need
Speaker: 25 people to spend 25 hours doing a full root cause analysis.
Speaker: Just like not every drug event requires that, but it ought to be present in our thinking as we think about what it means to be a high quality system, a healthcare system.
Speaker: It ought to include our management of disrespect and our solutions to decrease the amount of disrespect.
Speaker: And I guess two points to those comments, Sam.
Speaker: On one hand, when I was reading about this and thinking about it, I also kind of was thinking along the terms of a dose response.
Speaker: So one very large dose can be very harmful, but small doses repeated enough times can probably cause as much harm to a patient.
Speaker: And I think those are things that we need to think about as well.
Speaker: That's a great point.
Speaker: And the second thing is that when we really think about creating value for our patients, it's really about improving patient outcomes and their experiences at the same time that we lower cost.
Speaker: And I think that part of the patient experience has had a bad name for a lot of physicians because all they think about is Prescani scores.
Speaker: But respect in that area is probably something where we have tremendous opportunity to make a difference.
Speaker: Yeah, I personally tend to think of those HCAP scores that get administered by Prescani and other corporations as a mostly statistically meaningless number that goads us to try to do the right thing.
Speaker: So I have kind of a mixed relationship to them.
Speaker: I don't for a moment believe that the HCAP scores accurately represent what people think they're accurately representing in most circumstances.
Speaker: And at the same time, I think they bring to our attention and the attention of administrators that absolute importance of humanizing the encounters that we have with people, not because CMS is going to get mad at us if we don't do it, but because it's the right thing to do.
Speaker: We are human beings.
Speaker: These are our peers.
Speaker: They deserve that respect.
Speaker: And I think that the unintended consequence of treating your patients with respect, from my perspective, would be that your self-respect will increase.
Speaker: And I think that is very important in terms of burnout, which is very prevalent.
Speaker: And we'll get to that in a second.
Speaker: But also, I would imagine that the more you treat your patients with respect, the more likely you are to treat your colleagues and the rest of the team with respect.
Speaker: And overall, it has to be a contagious effect.
Speaker: kind of environment that really changes the way that ICU feels.
Speaker: Yeah, I agree.
Speaker: I'm a scientist, so I always want to pause and think what the data are.
Speaker: The data are that disrespect is contagious.
Speaker: There's pretty good data for that, actually.
Speaker: Whether respect is contagious, we think so.
Speaker: The research has not been well done yet.
Speaker: But if disrespect is contagious, it stands to reason that the elimination of disrespect will interrupt the contagion of disrespect.
Speaker: So at some level, I think we already know the answer.
Speaker: The other thing I would say that we need to call out is that administrators are culpable in the disrespect of patients when they create work environments that are highly toxic to the clinicians.
Speaker: So I don't want the clinicians to think, oh, my boss is a jerk, so he's the reason that I'm causing all this trouble for patients.
Speaker: That's not the right answer.
Speaker: It's also not the right answer to say it's all about the clinicians.
Speaker: And the thing that worries me as we become much more MBA driven in medicine is that people tend to think that if they're just running human resources and strategy and the patient ratios and RVU targets and all that kind of stuff that the MBA crowd feel is their bailiwick, it can't possibly be my problem if my clinicians aren't treating people well, or certainly not my fault.
Speaker: But the reality is that when administrators treat their clinicians disrespectfully, that disrespect is contagious.
Speaker: And I think we need to get more and more of the administrative people mindful of that, that when you treat your clinicians disrespectfully, you increase the chance that they in turn will treat others disrespectfully.
Speaker: And I think that that really rides right into what I wanted to ask you next, which is also the system's responsibility in creating environments that lead to burnout.
Speaker: I mean, there's definitely a lot of factors internally, but in terms of barriers to the practice of respecting the ICU, do you want to comment on empathy fatigue and a little bit on burnout?
Speaker: Yeah, that's the concern.
Speaker: Again, like we talked about earlier, if people get too invested in compassion, they can be exhausted.
Speaker: None of us can tolerate the death of multiple intimate friends over the course of a month.
Speaker: It's just too much.
Speaker: So if we're not careful, we can run out of empathy.
Speaker: And that's something we have to manage.
Speaker: Sometimes when you think, I've got to start behaving more respectfully, we think, oh, I've got to have an intimate emotional bond with every person that I treat.
Speaker: And that's actually not
Speaker: true and may not be the right target for us because we have to have the capacity to care for the people that continue to come into our care.
Speaker: So there are risks and there are data that suggest that if you identify too powerfully with too great an emotional resonance with patients and families that you will develop empathy fatigue and
Speaker: are at risk for burnout.
Speaker: Now, burnout's an interesting question, needs more research, because there is some evidence that if you humanize carefully, avoiding excesses of empathy that will overwhelm the clinician's psyche to the extent that the clinician can no longer function correctly, then humanization, respect, can actually decrease burnout.
Speaker: People can feel connected again to the things that called them into medicine in the first place.
Speaker: So we're really in a Goldilocks kind of place, or if you're a classic philosopher, you're looking for that Aristotelian mean.
Speaker: What you're after is the sweet spot.
Speaker: Practicing respect without becoming so emotionally overloaded that you have no capacity to continue to care for additional patients.
Speaker: And so one of the reasons that we call for research in that perspective piece in Blue Journal
Speaker: is precisely because we need to find that Goldilocks spot where the porridge is not too hot and not too cold and the chair is not too big and not too small.
Speaker: And looking for that sweet spot is the work of good research, good collaboration with patient advisory councils and with the patient advocacy groups, thinking together, how do we find the sweet spot?
Speaker: Because I think that we will have that capacity.
Speaker: And the sweet spot may vary slightly based on the
Speaker: the location and structure of the hospital, or the locus of healthcare being provided, whether that's a hospital or a clinic.
Speaker: It may also depend on the cultural background of the patients and the cultural background of the doctors.
Speaker: There will be this ongoing navigation and discussion that comes to something like that sweet spot.
Speaker: What we've really been advocating, in addition to the research, is a model that says that we are partnering in this.
Speaker: We are teams, and those teams include clinicians and patients and families.
Speaker: It includes the whole crowd.
Speaker: And by creating that capacity to have functional teams, we make ourselves capable of developing in useful and important directions.
Speaker: that will allow us to accommodate shifts or local variations, et cetera.
Speaker: And I think that the first step, obviously, is recognizing we have a problem
Speaker: Yeah.
Speaker: The second question, I mean, is, like you said, is finding through science, what is that sweet spot, which I think is true because we think of everything being a linear relationship, more is better, but probably for most things in life and definitely in the ICU, they're nonlinear relationships and there might be more like you's, that there's a sweet spot and then you get in trouble.
Speaker: But I also, I think you're right.
Speaker: And the other thing that I always think about, Sam, is how do you model, how do you teach people to be respectful?
Speaker: Obviously, as a parent, I've always grappled with this in one way as example, but how do you model these behaviors?
Speaker: And I think the examples you gave are very specific examples that we can teach people to think about, but I'm sure that this would also be the topic of future research with your group.
Speaker: You're absolutely correct that we need more research to understand how to model it.
Speaker: My sense has been that it's important to see it executed well.
Speaker: So I try to make sure that I draw attention to people who do it well and encourage people to spend a little bit of time in the presence of people who do it well.
Speaker: I think that's important.
Speaker: I think for, I mean, essentially every person I know wants to do good and be good.
Speaker: Now we have blind spots, we have things that pull us in the wrong direction, we have exhaustion, we have things that get in the way of our wanting to do good and be good.
Speaker: Most commonly, I think, it's failures of vision and failures of consistency.
Speaker: And for failures of vision, I've found personally, and I think others have as well, that actually getting advice and collaborative input from the other participants is huge for changing your vision.
Speaker: So I strongly recommend that ICUs, even if they can't pull off a full patient family advisory council,
Speaker: that they, a couple times a year, identify some graduate from their ICU, whether it's a patient or a family member or both, and then invite them back for a debrief.
Speaker: And have the debrief be with the unit management and with one or two of the clinicians that are really invested and with the clinicians that cared for them.
Speaker: And then just talk it through, just say,
Speaker: We're so glad to see you again and we want to know what we did well and what we could have done better and tell us about your experience of it.
Speaker: What were the things that really worked?
Speaker: What were the things that we could work on to improve?
Speaker: Now you have to be thoughtful that some people will decline the invitation because of PTSD or not feeling ready to discuss things.
Speaker: You can sometimes meet with them off the unit to lessen the risk of
Speaker: PTSD in my experience even though PTSD probably affects somewhere between 15 and 35 percent of ICU graduates only a minority of those with measurable PTSD symptoms are unable to interact with the healthcare team afterwards especially in a neutral location and then through that process you learn a little bit more you get a little bit more understanding and then you are going to find people who don't have the PTSD so they're able to come back to the ICU environment who are
Speaker: pretty good at communicating, and who have some memorable stories.
Speaker: And then you bring those people to your nursing and services or to your division meetings for the docs, and you have them present.
Speaker: You have them talk about it.
Speaker: And it's been our experience that having those actual graduates of the experience describe what it was like, that's been most useful for training and
Speaker: transforming around the vision in disrespect.
Speaker: For continuity, for follow through, that's a little harder.
Speaker: We as human beings notoriously do worse than we intend in part because we sort of forget.
Speaker: And I think having periodic recharges can be helpful.
Speaker: And recharges that indicate that the administrators who manage the system
Speaker: and the colleagues care about it.
Speaker: So we've tried periodically to have, even though we've really tried to train up this group really well, to periodically have refresher in-services or refresher division meetings where we have lectures from, or brief talks or question-answer periods from patients and families that have come out the other side.
Speaker: It does take a champion, as I think we've all known.
Speaker: You can't make something happen
Speaker: without either some sort of regulatory oversight that's sort of exhausting and soul-crushing or with some local champion.
Speaker: But it's been my experience with local champion and reasonably clear-seeing administrators that even relatively informal mechanisms can make it possible.
Speaker: People want to be good.
Speaker: They just sometimes don't see clearly and sometimes are exhausted or in
Speaker: systems that interfere with their capacity to be as good as they'd like.
Speaker: Yeah, and I think that it's a common theme in life that we focus on the differences we have with other people, yet at the core, we are very much alike and want the same things.
Speaker: We actually, as Simon, several of our programs have done something called the celebration of life, where we invite graduates of the ICU or families of patients who died for a day where we meet with the staff, talk about different topics.
Speaker: Don't do it maybe such as a
Speaker: systematic debriefing but what we have found is not only it's very powerful for the patients and their families but it's extremely powerful for the staff in creating that common sense of purpose which I think is probably one of the most important antidotes to burnout and I think that has many benefits yeah that's great
Speaker: So this has been, I think, a fascinating discussion.
Speaker: I think that a lot of topics that are extremely relevant to where we are today in critical care, I'm sure we could go on for a long time, but I want to be obviously very respectful of your time.
Speaker: And what we'd like to do, Sam, at the end of every Critical Matters episode is just ask our guests a couple of general questions just to tap into their wisdom of life in general outside of the fast lane.
Speaker: Would that be okay?
Speaker: Sure.
Speaker: So the first question relates to books, and what book or books have influenced you the most, or what book have you gifted most often to others?
Speaker: I have to say my favorite book for a very long time is Speak Memory by Vladimir Nabokov, or Nabokov, some people will say.
Speaker: It's his memoir, and it's this sort of
Speaker: It's this celebration of the power of language and perception.
Speaker: And I love it.
Speaker: I read it.
Speaker: I read it probably every other year still.
Speaker: Just this sense of being alive to awareness and alive to language, the power of language.
Speaker: Not everybody likes Nabokov, but I think his love of language is really quite illuminating.
Speaker: And I think very timely for where we are today in education, where it seems like everybody is learning from tweets or from PowerPoint slides.
Speaker: And I always worry how that affects the way we think about problems in terms of the ability to really articulate an idea and think about it through language, which I think is very powerful.
Speaker: I have not read this book, but definitely will get it and try to explore Nabokov a little bit more.
Speaker: The second question... I try to read about a book a week.
Speaker: I just feel like that's part of how you stay alive.
Speaker: I'm with you.
Speaker: I think it's sad that we seem to be separating ourselves from books because I think there's so much to learn from them.
Speaker: Well, and I think that it really speaks also to what we're talking about, the beginning with dignity and respect, is that the true questions of humanity remain the same over the centuries.
Speaker: And people have explored these questions a long time ago, where you're reading the Stoics or reading Thoreau.
Speaker: I mean, these are all questions that are still 100% relevant to our lives today.
Speaker: And I think that through reading, you can really learn a lot about yourself.
Speaker: Yeah, I agree.
Speaker: The second question is, what do you believe to be true in medicine or in life that most other people don't believe?
Speaker: I think it's always hard to know what other people do or don't believe.
Speaker: I'll confess that I am practicing Mormon, which is an odd American religious tradition, which I love a great deal.
Speaker: And I think as I've pondered more and more in the ICU, in my scientific work, in my intellectual work, I have this sense that this is not all there is.
Speaker: I'm not trying to go ultra mystical.
Speaker: I'm not trying to make any big sweeping religious statements, but I just have this sense that the mere everyday, the mere physicality is not all there is.
Speaker: And that sense that there's more to us than just our flesh and our bones is deeply meaningful to me.
Speaker: And I think motivates a lot of this work that I'm doing to try to
Speaker: understand how we identify, treasure, and preserve that which is marvelous in all of us.
Speaker: And I think, I mean, it speaks very powerfully to the fact that sometimes it's not having the right answers, but having the right questions that are important.
Speaker: And really thinking about those big questions, I think, can guide everything we do, whether professionally or just in our life.
Speaker: Yeah, absolutely.
Speaker: And the last closing question is, what would you want every sound critical care and every intensivist that listens to this podcast to know?
Speaker: To this question of respect and dignity, I think we ought to know something human about every patient we treat.
Speaker: At a minimum, their preferred name, but ideally some story, some story.
Speaker: fact or reality about them that makes them just a little more vivid for us as human beings.
Speaker: That's what I really try.
Speaker: Everybody I meet in the ICU to know just a little bit more about them than their physiology.
Speaker: And I've been really nourished and enriched both humanly and spiritually and intellectually and even scientifically.
Speaker: by being open to those little glimmers of distinctive illumination that come from the individuals I meet.
Speaker: Absolutely.
Speaker: And I would push it one step forward and say that it probably applies to everybody you work with.
Speaker: Learning things about the people around you that make them human definitely makes the connections a lot stronger and makes difficult times easier to deal with.
Speaker: Yeah, you're right.
Speaker: You're right.
Speaker: Absolutely correct.
Speaker: Well, I really want to thank you for your time.
Speaker: This was a fantastic conversation.
Speaker: I look forward to reading the books you recommended.
Speaker: I also look forward to seeing some of the research that your group will put out in this topic and hope to have you back on Critical Matters as a guest again.
Speaker: Okay.
Speaker: Thank you so much, Sergio.
Speaker: It was great fun.
Speaker: Thanks again for listening to Critical Matters.
Speaker: Make sure to subscribe to this podcast on iTunes or Google Play.
