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: Sound Critical Care provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now your host, Dr. Sergio Zanotti.
Speaker: The end of May has marked a somber milestone in the COVID-19 pandemic in our country.
Speaker: 100,000 Americans have died due to complications caused by COVID-19.
Speaker: This is a staggering number.
Speaker: The fact that it has occurred in the span of weeks to months makes it even more difficult to fully understand.
Speaker: It invites us to pause.
Speaker: In today's episode of the podcast, we will discuss another unexpected consequence of the COVID-19 pandemic, the challenges it has presented to healthcare workers trying to practice patient-centered
Speaker: compassionate critical care.
Speaker: These challenges have been manifested on many aspects of care in the ICU, perhaps most strongly on our ability to communicate with critically ill patients and their families and our ability to provide a good death to our patients.
Speaker: We are very fortunate and honored to have Dr. Silvia Perez-Proto as our guest.
Speaker: Dr. Perez-Proto is an anesthesia and critical care attending at the Cleveland Clinic.
Speaker: She's a faculty member of the Department of Intensive Care and Resuscitation
Speaker: and is also the medical director for the End of Life Center at the Cleveland Clinic.
Speaker: Her areas of interest include advanced directives, end of life care, healthcare communication, organ donor management, and general topics in critical care medicine.
Speaker: Sylvia, welcome to Critical Matters.
Speaker: Thank you so much for having me.
Speaker: So I think that a very interesting topic today to talk about.
Speaker: I think that for the last several weeks to months, the whole critical care community has been
Speaker: really deep in and dealing with COVID-19 as we were discussing before we started recording different numbers and surges in different places of the country but something that has touched all of us as professionals and that I think is very unique in our life in our lifetime because it really has affected every single country in the world at the same time so maybe I we can start by something that's pre-COVID and that's a very I think
Speaker: popular and watched video that your institution has released several years ago talking about walking in the shoes of others, the empathy video that I think has received millions of views on YouTube.
Speaker: And I just wanted to start with maybe your impressions on the video itself or what it means and what empathy means in your day-to-day as an intensivist and somebody who's really centered on patient-centered care.
Speaker: So for me, this video has a lot of meaning.
Speaker: And every time I watch it, I get a different flavor, depending on what I've been exposed in the ICU or what is happening in my life.
Speaker: And I teach healthcare communications, and we use it to kick off a topic of empathy.
Speaker: So I see it very, very often.
Speaker: And every time
Speaker: it hits me differently.
Speaker: And I think the main power of that video is to help us understand what it means to be in the other shoes, not only for our patients or their families and loved ones, but also our colleagues, our coworkers, our residents and fellows, our international students,
Speaker: So I think empathy is key to keep us connected to our core of why we are physicians in the first place.
Speaker: And I think that it's almost like the sine qua non in terms of providing patient-centered care and really making a difference because like you said, Sylvia, without understanding what other people are experiencing, whether it be a colleague during COVID-19 and the stresses that they have or the patients that we're treating, or in this case,
Speaker: the families who are unable to be at the bedside during this time, I think it's very difficult to really create that connection and ultimately make a difference, which is what we're trying to do.
Speaker: Yes, I think it has been the most difficult part of COVID for me is the inability to connect with the families all the time as usual and to see our patients alone and
Speaker: Sometimes with the lidium and nurses and us helping the patients.
Speaker: However, we know that the main help would be the wife, the daughter, the husband there, right?
Speaker: And those are the things more difficult that have been for us, even though we have some exclusions.
Speaker: So we have...
Speaker: we permit to come family members or loved ones when patients are dying or one visitor for mothers that are going to get had birth or pediatric populations.
Speaker: However, it seems very, very little, you know, when patients are like 17 days in the ICU,
Speaker: And then they couldn't come because the patient is not at the end of life.
Speaker: We are fighting and everything is going in the right direction, but there's no exceptions to make for that family to come.
Speaker: And connections virtually, we are doing a lot.
Speaker: However, you know, this personal touch is missing.
Speaker: I agree.
Speaker: And I think that it will dive more into these challenges with COVID
Speaker: But I think that also it illustrates how as we were preparing for all this and starting to see this unfold, there's always aspects that we can't anticipate.
Speaker: And I think this is one of those.
Speaker: Everybody was worried about what drug to use, what modality for mechanical ventilation, number of ventilators, number of beds.
Speaker: But really, other than reacting to this disconnect, I think nobody proactively was able to say, what are we going to do to make sure that communication
Speaker: is as best as it can be during these times.
Speaker: And that's just, I think, another very interesting lesson.
Speaker: What I would like to say.
Speaker: So I can share that actually Ohio has been amazingly managed by our leaders.
Speaker: And then we had some time to prepare.
Speaker: So, for example, in the first two or three weeks of the quarantine here in Ohio, we worked
Speaker: like day and night to bring up programs like care companion that is a module that patients can open in the phones and they can enter all the symptoms and then
Speaker: person from the clinic follow up every day and connect with the patients.
Speaker: And even there, we put some information about advanced directives and helping patients to complete the documents and upload them to the system.
Speaker: We also were able to prepare scripts on how to share prognosis.
Speaker: And if we couldn't allocate ventilators to every patient what to do and how to connect
Speaker: and how to convey this information that is super hard.
Speaker: And we also work with other institutions in Cleveland to set which are the criteria that we will use in case of a surge and inability to have enough ventilators for all the patients.
Speaker: Actually, the amazing work by the Ohioans helped us to have time to prepare.
Speaker: And I can share with you that many of our courses are free until the end of June in our website, in the Cleveland Clinic, about communication skills.
Speaker: So we'll definitely link that on the show notes because I think that communication skills are very important pre-COVID.
Speaker: And I think COVID just highlighted how important they are
Speaker: and how more challenging it is.
Speaker: But one thing I would like to do before we start is maybe talk a little bit about words and definitions, because I think they do matter in terms of understanding concepts.
Speaker: And there's a lot of concepts that I see being thrown around a lot in healthcare and the ICU, but they don't always mean the same things to everybody.
Speaker: And they don't always are acted upon in terms of how many people interpret them in reality.
Speaker: And I just wanted to maybe
Speaker: do a little play with words and just have you comment on these in terms of your perspective and how you see it from your shoes.
Speaker: And would that be okay, Sylvia?
Speaker: Yes, of course.
Speaker: So maybe start with patient-centered versus clinician-centered.
Speaker: So I can tell you that when I started my training years ago,
Speaker: I was taught by many professors, like, this is what we will tell the patient, and this is what the patient should do.
Speaker: It was little offering of options or little of exploring patient's wishes or goals.
Speaker: And then with EARS, we have changed that to an approach where we explore what the patient understands of the current situation.
Speaker: And then we deal from there in order to talk about prognosis.
Speaker: And then we explore what is most important for you.
Speaker: I think that is the main question.
Speaker: And then we can understand that we usually assume things that are not true.
Speaker: And also using open-ended questions where the patient goes wherever they want, not where we want them to go.
Speaker: That keeps an understanding of what is important for them.
Speaker: What are the wishes, the concerns, the worries?
Speaker: And then we offer treatment that align to those wishes and make a plan together with the patient.
Speaker: It's not me telling the patient what to do, it's having a plan that makes sense to that patient in that moment.
Speaker: So that I think is the main change over the years, what I've seen from the old school to the new approach.
Speaker: And I think that clearly there's a lot of value, right, in understanding other human beings and what's important for them.
Speaker: But I do believe also that a lot of us grew up, like you said, in that old school model, were trained in that model.
Speaker: But also when you really reflect on a lot of the behaviors that we and colleagues and people who trained us had back then, it really centered around the needs of the clinicians, not the needs of the patients.
Speaker: And I think that really moving towards what does the patient need and what's important for the patient is really, I mean, the whole process that you're talking about that I think that we sometimes do it better than other times, but also I think between teams, some doing better and some do worse.
Speaker: But the point is that I think for all of us, no matter where you are in this journey, there seems to be opportunity for doing it better, right?
Speaker: Yeah, even the word patient, why is patient?
Speaker: Because they have to wait for the doctor, right?
Speaker: Even the name of patient, like you like to talk about words.
Speaker: So one of the things we do at the clinic in the Office of Patient Experience where the End of Life Center is part of is bringing patients to
Speaker: highlight what we are doing to give us light in our processes, if they are okay or not, if we get their input.
Speaker: Even for when we do new buildings, we bring them in to understand if the building itself and the office are okay for them.
Speaker: Up to, for example, when I work on the
Speaker: communication skills for end of life or giving bad news.
Speaker: We actually check with real patients that are volunteers that help us with these activities.
Speaker: I think bringing the vision of the patient themselves help us to make different approaches that are more effective towards patient experience.
Speaker: And I think that that's a very important lesson that really, I mean,
Speaker: It's something that we probably learned in medicine from other businesses.
Speaker: I know that it's a very lean approach to really seek the voice of the customer and our customer, obviously our main customer is the patient.
Speaker: But I also think that it's a great lesson for our critical care colleagues who are listening to this because you can involve patients in your critical care committee, your local patients and making sure that you seek an understanding of what's important for them when they're in the ICU.
Speaker: are the things that you are putting your time and effort on important for the patients.
Speaker: Ultimately, it's about improving care, but having that perspective is very, very valuable.
Speaker: And I think that that's a great lead into the next step pair, which is goals of care and end of life, which I think a lot of times people assume are all the same thing, but they're really not, right?
Speaker: No, they are not.
Speaker: So I understand that,
Speaker: So what I feel about these words, I prefer to talk about advanced care planning.
Speaker: And I like to say advanced care planning because it's any person when we are adults, 18 or older, is what I want for my medical care to be.
Speaker: And this starts when you are healthy because anyone, you or me, can have an accident or a stroke anytime and then we become incapacitated and be
Speaker: in the ICU and then our loved ones have to make decisions for us.
Speaker: So that's why I think the best thing is to think about any person who have documents in place who is going to make decisions, these are the advanced directives, and then have the conversation with the loved one.
Speaker: And that could be very difficult to do yourself because sometimes you say, what I'm going to talk to them about.
Speaker: So there are many guides out there.
Speaker: We use the conversation project.
Speaker: If you look at it in the internet, you can find them and they are very easy.
Speaker: They are validated by people that are not sick.
Speaker: And then what are the important things to talk to your loved ones?
Speaker: And then when you are seriously ill, let's say you have a diagnosis, you are fighting cancer, like in a recurrence, like you are with a problem, breathing problems or heart problems.
Speaker: So goals of care comes up now as a way to convey to the medical team, these are the things that are important for me.
Speaker: And then for the medical team to respect those wishes.
Speaker: End of life care, I think until the patient is dead, we don't know if we are really in end of life because sometimes in the medical community, we are always thinking to keep the patient alive and to extend the life.
Speaker: However, for many patients, when you talk to them, a number of days is not the goal.
Speaker: They want quality of life.
Speaker: And then we, again, we assume that patients want to live longer only.
Speaker: And so it's important to ask the question, how much you want to go through in order to get more time?
Speaker: So end-of-life care, for me, is when a patient is saying to us, you know, I want quality of life.
Speaker: I know that my disease cannot be cured.
Speaker: And then the patient and the physician or the provider arranges to do comfort measures only and pursue quality of life day by day.
Speaker: So for me, it's that end of life and hopefully there's a hospice in place where they can have better days and then the family is supported as well.
Speaker: The loved ones are supported.
Speaker: So I don't know, I think I walk you through all the stages from being totally healthy up to being in measures of comfort only, that there's always time to have the conversation with loved ones and to have plans.
Speaker: So it's not stressful.
Speaker: And then we can leave the emotions without stress.
Speaker: And I think that along those lines, Sylvia, I also find that often, and I wanted to hear your comments, we as clinicians provide more options that are medically based as opposed to ask questions that are more trying to understand what's important for that person as a human being, right?
Speaker: Is there, I mean, can you talk a little bit about that distinction and how important that is when we're trying to understand what would be patient-aligned care?
Speaker: Yes, I think that one is the medical training that we have, has been always to save lives.
Speaker: And now later, I know that many programs are including this and dying as a topic to discuss during training.
Speaker: I think the main important thing is to acknowledge that death is a normal part of our life cycle.
Speaker: And actually, this was what inspired Dr. Gosgrove years ago to establish the End of Life Center based on the fact that death is a natural act.
Speaker: And I think based on that, we need to understand that we are not failing when our patients die.
Speaker: So exploring what the patient wants and what are their goals,
Speaker: and also being able to share prognosis honestly and with empathy is the key.
Speaker: So patients can plan their life.
Speaker: I always share the part of the book of When Breast Becomes Air by Paul Kalanisi, who was a neurosurgeon.
Speaker: And he diagnosed himself with cancer
Speaker: And he said that depending on the time that he had to leave, it was the decisions to make.
Speaker: So he said, if I have more than one year, I want to go back to the OR and operate.
Speaker: If I have less than one year, I want to write a book.
Speaker: And if I have less than three months, I want to go home and spend time with my family.
Speaker: So I think that
Speaker: that part of the book helped us understand that it's so important to share honestly what is happening and what it looks like the future of the health of the patient so they make decisions based on their wishes and values.
Speaker: So I think why we don't
Speaker: we are not that honest sometimes is because we are afraid of talking about this.
Speaker: We are afraid of leaving the patient without hope.
Speaker: And we are uncomfortable with saying even the word death.
Speaker: Actually, I did a training to my fellows and they couldn't say the word death.
Speaker: And actually, I named the course Learning to Say the Word Die.
Speaker: So basically, I think being able to share the best case scenario and worst case scenario so they know what can the best way and we
Speaker: keeping hope.
Speaker: However, we are being honest to tell them what is worst case scenario.
Speaker: And sometimes it's death.
Speaker: And you can have a death in the ICU with all the machines and fighting until the last minute.
Speaker: And when I know that the patient wants that, I do it with in peace.
Speaker: And I had many cases where I remember in this moment one patient who the mother told me,
Speaker: He wants everything done because he wants to live as much as he can for his kids.
Speaker: And you know, we fought for his life and unfortunately he died.
Speaker: But we did everything, even when we thought that the chances were very little, we did it with a lot of energy because we knew that it was his wish.
Speaker: However, when we are,
Speaker: treating a patient in the ICU.
Speaker: And I'm sure you shared this experience when we think that the odds are very, very little to survive.
Speaker: However, there was no discussion and nobody knows the wishes of the patient.
Speaker: It's hard because we are doing things that we don't know if the patient wanted that.
Speaker: And I think that also another point that comes to my mind based on that discussion, Sylvia, is related to as clinicians,
Speaker: It's very easy to say somebody understands and is reasonable when their views align with our views.
Speaker: But as soon as the family or the patient is not aligned with what we think is best, they become a difficult conversation, right?
Speaker: They become a difficult or unrealistic expectations.
Speaker: And I think that it's our job to provide the best information so they know what to expect.
Speaker: And then I think it's our job
Speaker: to find what the patient wants with that information and to do the best we can to provide that.
Speaker: And I think that that's where sometimes it becomes difficult, but I think it goes right to your example.
Speaker: If the patient understands that their chance of dying is extremely high, but what they really want is to fight till the end, like you said, you do it at peace, knowing that we're doing the best we can in care that's aligned with what they want.
Speaker: Yes, yes, totally.
Speaker: And I think that
Speaker: decrease our moral distress.
Speaker: I think we have a lot of moral distress when we see inconsistencies between teens treating the patient and the family and the nursing.
Speaker: So being everybody on the same page is super important to decrease the moral stress in the nursing, in us, in the family, and the patient if he's aware.
Speaker: And I think that that's a very important point because when we talk about moral distress, I think what we're really recognizing
Speaker: is a dissonance between what we're doing and expectations or what we think should be done.
Speaker: But like you said, if we do a very good job in understanding what each patient wants, we're much more likely to decrease that dissonance, even if sometimes we are doing care that ultimately leads to somebody dying, but that's what they really wanted was to fight till the end.
Speaker: And in some situations, that is the best we can do.
Speaker: Yes, yes, totally agree.
Speaker: So another, I think, duo of words that I wanted to share with you, which I think sometimes also people confuse, I mean, especially when we talk with our colleagues outside of the ICU or other members in the ICU team is DNR versus comfort measures only.
Speaker: Oh, yes.
Speaker: So, DNR means do not resuscitate.
Speaker: If we go back to the meaning of that, resuscitation or ACLS protocol or CPR, how many words we can do in order to express the protocol we do in order to restart the heart if the heart stops or restart the breathing in a patient who stopped breathing, it's a treatment, right?
Speaker: And do not resuscitate.
Speaker: is like not give that treatment because it's not effective in this situation.
Speaker: So one of the ways that would be nicer to explain is allow natural death without attempting a recitation.
Speaker: However, these that I wanted to change the wording
Speaker: but you are in a state where we some laws and you have to respect the law unless you want to try to change it.
Speaker: So in Ohio, we have the DNR order in the state.
Speaker: So it's hard to change it to the notion of allow natural death or in the same concept.
Speaker: So DNR means that we will not provide resuscitation techniques
Speaker: that includes sometimes chest compressions almost always, and then intubation, shock, IV medication, et cetera, to try to restart the heart.
Speaker: But we need to understand that this is a treatment that has that indication.
Speaker: it's not a right of the patient to have resuscitation, right?
Speaker: So that's the thing that that makes sometimes in the minds of people when we are discussing these topics.
Speaker: So comfort care only is when we are treating a patient who the expectancy of life is low, so the patient is going to die, it's terminal.
Speaker: And we cannot give any more medications to extend the life or treatment to extend the life because they are not going to work.
Speaker: And then we only give measures of comfort.
Speaker: So our care changes from directed to the disease to directed to comfort.
Speaker: And there's something that, you know, you see, you can hear my accent.
Speaker: I'm not, I have English as a second language.
Speaker: So when I came here and I hear saying we are withdrawing care in that patient because the patient is terminal, it's not going to survive.
Speaker: So that sounds horrible to me.
Speaker: And unless I start asking, and it doesn't sound good for many people.
Speaker: And so we have to change the world into withdrawing life support in those cases instead of care, because we will care and provide everything to keep the patient comfortable.
Speaker: while sometimes we stop the treatment that are not helping anymore for the goals of being comfortable.
Speaker: Yeah, I think that withdrawal of care is a term that is frequently utilized, I think, in ICUs and especially among intensivists.
Speaker: If they're signing out to each other, they might say, well, this patient, we're going to withdraw care.
Speaker: And I think whether you speak English as a first or second language, I think the connotation of that is not a positive one, right?
Speaker: Because
Speaker: it is probably at that time when the patient and the family need the most care.
Speaker: And a palliative care doctor once shared with me that his approach to that is to talking about intensive comfort measures.
Speaker: So we are transitioning to intensive comfort measures.
Speaker: And I think that it speaks to what you were saying, but it's probably a much more appropriate way of framing things because I do believe, Sylvia, that a lot of times words carry meanings
Speaker: that we don't even appreciate at the moment, but it sets a tone for that patient.
Speaker: If I got signed out that this patient withdrew care, I'm less likely probably to feel compelled to go and check on them because the whole connotation is that we're walking away from that patient.
Speaker: If somebody told me we are doing intensive comfort measures in my subconscious, I'm more likely to go and make sure that we are providing the comfort measures because we're doing intensively.
Speaker: So I could go and check on that patient.
Speaker: And I think that
Speaker: These are terms that are very important, what they mean and what people interpret.
Speaker: I think going back to your comments on DNR and comfort measures only, a lot of times people will ask me in the ICU, why is this patient coming to the ICU, their DNR?
Speaker: Well, if they don't code, there's a lot that we can do for them in the ICU.
Speaker: And as a fact, the majority of our patients in the ICU don't code, right?
Speaker: We're doing other stuff.
Speaker: So I think this is why I think understanding these terms is always important.
Speaker: And I thought it was a good
Speaker: a good point to start.
Speaker: But let's start navigating now towards more challenges in real life.
Speaker: And I wanted to just start with your take on some general challenges in practicing compassionate, patient-aligned critical care in terms of understanding patients and respecting their preferences, and in terms of the communication with patients and their families.
Speaker: Just some general challenges that you have seen as director of the End of Life Center
Speaker: and things that we talked a little bit about before, but also that you talk a lot about in your courses?
Speaker: So I think one of the challenges, for example, when I'm discussing options with a family and the family asked me, what would you do if this was your mother?
Speaker: So I think it's a very tricky question and we have to be very aware of what to answer.
Speaker: So I normally say, if it's my mom, I would do what my mom wanted.
Speaker: So my next question to you is, if you have a conversation with the patient, what do you think he answered or she answered to you in this situation, he wanted or not?
Speaker: If they didn't have the conversation, then I would say,
Speaker: any signs or actions of this patient before that shows you what he or she will choose in this moment.
Speaker: So I always try to make these as a decision for the patient's wishes, not what we want.
Speaker: So I normally answer also that sometimes when we,
Speaker: are choosing for someone else, we have to divide ourselves, separate ourselves from our own feelings.
Speaker: And we have to think about what the patient wants or would have wanted.
Speaker: I think that is the challenge on how we communicate with families and help them to make the decision.
Speaker: The other thing I see many people
Speaker: to ask, do you want us to do everything?
Speaker: And if you ask the question like this, everybody is going to say yes, of course, do everything.
Speaker: The question here, the challenge is how to ask the question.
Speaker: And again, avoid the yes and no and open up, first of all, giving the information and then the options and then
Speaker: understanding the values of these patients.
Speaker: And then sometimes we have to make a recommendation.
Speaker: And I think making a recommendation helps families to make a decision towards keeping the full code and give us time to figure out what's going on with the patient.
Speaker: Or sometimes to say, you know, we are going to try to extend the life and get the patient out of the ICU, but if the heart stops, let the patient go in peace because it's not going to work.
Speaker: The resuscitation efforts are going to be futile in this case.
Speaker: And futile is a very complicated word as well.
Speaker: In our law, it's
Speaker: part of the law, futility is in our laws and sometimes we use it.
Speaker: I think it's better to say it's not going to be effective in order to translate it to families.
Speaker: So I think those things, separating our own values and wishes from what the patient wants, even as a doctor or as a family of loved ones is very important.
Speaker: Yeah, and I think that both of those, I mean, that you mentioned are very important, but especially your first point made me think, Sylvia, that we often will tell patients that it's not about, tell families it's not about what they want or what they think in a nice way, but it's about what mom or dad would want.
Speaker: Yet, if they were to ask us the question, what would you do?
Speaker: We usually respond based on what we think we would do.
Speaker: And that's the wrong response.
Speaker: Your response is the perfect one is,
Speaker: I would find out what my mom or my dad wanted, right?
Speaker: That's the, I think, a very important distinction that I think, I mean, helps align things.
Speaker: Another area that I wanted to ask you about, which I think you obviously have spent a lot of time thinking about, and I think express it with a quote that says that the biggest problem with communication is the illusion that it has happened.
Speaker: And this is something I see every day in the ICU, that
Speaker: clinicians are perplexed that the family does not understand what's going on when they've told them multiple times what was going on.
Speaker: Can you talk a little bit about that problem?
Speaker: Well, I think we sometimes underestimate how emotions can blunt what the families or loved ones can understand, or even the patients.
Speaker: So when you are stressed, you have fears, there's many things that can happen.
Speaker: in these families, you know, long years fight between two brothers or actually somebody lost the job or there's another death in the family.
Speaker: There's so many things that we don't know, right, that are going on.
Speaker: And then we are very perverse in very difficult words and we have to make an effort
Speaker: to go to the words that the patients or loved ones understand and understand the health literacy and talking that level of words.
Speaker: And I always say, you know, when I go to the lawyer, they start talking about these words and I don't know what they mean, right?
Speaker: So it's the same.
Speaker: We want a lawyer for me to explain the things in simple words so I understand what he's talking about or she's talking about.
Speaker: is the same, to adjust our work for the level of literacy.
Speaker: And also to understand that sometimes the families need to listen, to hear the words two or three times because they are very stressed to get everything in.
Speaker: And it's our job to be patient and to be empathic and explore.
Speaker: how much they want to know, what they understand.
Speaker: So then we build from there.
Speaker: And I learned that in a bad way because in my training, my first training, I didn't get any communication skill training.
Speaker: And then I remember going to a family and explaining that the patient had a cardiac arrest and we did this and that.
Speaker: And the family said, what?
Speaker: and they didn't even know that the patient was in the ICU and I was talking about all these things.
Speaker: And then that day I say, oh my God, I will start with a question.
Speaker: What do you know?
Speaker: And I learned it from in the bad way.
Speaker: So I normally teach my fellows and residents first start with a question to understand where they are and then you meet them there.
Speaker: Yeah, I think that asking questions is always a
Speaker: the right approach no matter what, right?
Speaker: It's about having the right questions and not having the right answers.
Speaker: So I wanted to maybe move a little bit deeper into COVID-19 and some of the challenges that we have faced along the lines of trying to provide patient-centered and patient-aligned care in the ICU.
Speaker: And maybe just you told us a little bit about the experience at the Cleveland Clinic and what has happened at Ohio.
Speaker: And obviously different states have
Speaker: have encountered different situations, but in one way or the other, a lot of the situations are similar in terms of how hospitals have closed to families.
Speaker: But maybe you could just start by sharing with us some of the immediate challenges that COVID has brought in terms of providing patient-aligned care in your experience at the Cleveland Clinic.
Speaker: So again, I want to be honest that we don't have the surge.
Speaker: So we have been working
Speaker: We have COVID patients, but we are not overwhelmed.
Speaker: So we are having the time to have the conversation with loved ones and we have the exceptions in place to bring one family member if the patient is at the end of life.
Speaker: However, I think the fact that the families are not there is one of the barriers.
Speaker: The other thing is the fear.
Speaker: So before, so always the possibility of death for anyone that is alive is there, but we don't talk about it.
Speaker: We don't see it.
Speaker: It's not that obvious, right?
Speaker: So now I think even in, it would be among the residents, there was like a movement of, well, should we do advanced detectives?
Speaker: And even myself, I had a conversation with my colleague because I was afraid of end up in the ICU.
Speaker: And then I talked to a friend and say, you know, I have two kids and I want to leave.
Speaker: And even though I'm in the end of life, I'm not ready to die.
Speaker: And so put me in ECMO if I need.
Speaker: And we laugh and we cry.
Speaker: And, you know, so I think the challenge was to bring death as a real thing.
Speaker: thing that it was always there right but now it's more more like it's closer so i think um that gave us opportunity for example we did a class with all the residents to give them opportunities to understand the advanced directive document and complete them and put them in the chart we also um again in this care companion tool we we offer these um uh
Speaker: help and spiritual care, doing virtual visits to help patients and loved ones to think about all these issues.
Speaker: So I think what this brought up is to the topic of death more broadly.
Speaker: And I think it's a challenge, but also it's an opportunity because
Speaker: I think when you talk about your possibility of dying, you are talking about how you want to live.
Speaker: And actually I had, I did for the first time, death over dinner virtual with my husband.
Speaker: And we had the conversation some time ago, and then we had this death over dinner event together.
Speaker: And we felt closer after it.
Speaker: I think we have to get the fears out and be able to open up to our loved ones to talk about this.
Speaker: So I think this problem is an opportunity.
Speaker: Absolutely.
Speaker: And I think that we never really can evaluate if something's good or bad, right?
Speaker: Unless it's over time.
Speaker: And a lot of times what seems to be challenging in a problem up front, in retrospect, like you said, was a great opportunity or was something that actually had a very positive effect.
Speaker: And I think that
Speaker: what you talked about is very interesting because I think that thinking about the world in general with COVID-19, the two things that I come to realize, Sylvia, is that life has always been uncertain and death has always been part of life.
Speaker: It's just that now the volume is super high because everybody's thinking about it at the same time.
Speaker: And that is, I think, very unique in terms of creating that opportunity that you were talking about.
Speaker: Yeah, yeah.
Speaker: So I think if we let ourselves in the fears and in the depression, and you know, we have so many, I want to be empathic with everybody who lost a family member and couldn't do a funeral as usual, or anyone who lost their job, or anyone who's not going to college anymore, and you know, the kids that are not schooled.
Speaker: So there are so many phases of these
Speaker: pandemic.
Speaker: But I learned from my father that to always try to see they have, you know, glass full and try to find opportunities in the problems.
Speaker: And, you know, I'm talking from someone who lost the father years ago.
Speaker: So I went through what is to lose a father in the ICU.
Speaker: So it's not that I am a
Speaker: like far away of suffering.
Speaker: What I'm trying to convey is that we have to find ways to get out of this.
Speaker: And if you don't find a way to try to get help, because one of the other problems that COVID brought is isolation sometimes, depression.
Speaker: We see many patients are not seeking care.
Speaker: So the MI, like myocardial infarction,
Speaker: Heart attacks are not in the EDs anymore.
Speaker: Where are they?
Speaker: So people are afraid of going to the hospital to seek care.
Speaker: So these are all the consequences of the pandemic.
Speaker: So my main message here is if somebody is feeling that cannot manage these social isolation or whatever is happening to get help because virtual
Speaker: virtually we can help patients going through depression, anxiety, et cetera.
Speaker: Absolutely.
Speaker: And I think that along some of the comments that you've made throughout the conversation and also thinking about COVID-19, I'm based in Houston and we obviously had our share of patients, but we didn't have that surge either like some other places experienced.
Speaker: But being part of a large group, I did have conversations with colleagues who
Speaker: who were in New York City, who were in areas like California, and other areas that really had, I mean, amazing surges in terms of the numbers of patients.
Speaker: And it seems that the three themes that emerged that were problematic in terms of providing this patient-centered care were number one, in some places, the numbers were so overwhelming that literally the providers just didn't have time to talk with families.
Speaker: that definitely was a problem.
Speaker: Number two was that because families, like you said, and this happened in every hospital in the United States, were not present, having those discussions, those updates, having those conversations became much more difficult.
Speaker: And number three, which I wanted to hear a little about before we go to our next topic, was the fact that a lot of patients died by themselves.
Speaker: And if you could comment a little bit more on that, Sylvia.
Speaker: Yes.
Speaker: One of the things I want to add in the second point is that sometimes the disconnect between the loved ones and the patient, because if you are there at the bedside, you see when the patient is moving that is suffering with pain, for example.
Speaker: If you are from home, you are seen in a camera like in the iPhone, or it's hard to understand how the patient is living this time in the hospital, in the ICU.
Speaker: So then it's more difficult for the team to explain to the family how the patient is doing if the patient cannot speak by themselves.
Speaker: And then, of course, the death alone.
Speaker: We wanted not to have anyone die alone.
Speaker: So that's why we did this exception.
Speaker: However, I know that many places, there's not enough time.
Speaker: And then patients die in and out.
Speaker: And I will tell you that I know that nurses and physicians are trying to be there, you know, with the patients in order not to let them die alone.
Speaker: However, in the surge, it's not always possible.
Speaker: And this is a moral distress for the whole team.
Speaker: So in our hospital, even with our exceptions, we had a case where we told the family and they were coming in the drive, the patient died.
Speaker: So the patient died with us there and not the family.
Speaker: And another 91-year-old patient of mine with six kids, she died with only one at the bedside because we couldn't bring the six of them.
Speaker: So these are hard, it's hard and this happened like one month ago and I still remember.
Speaker: So, and it's going to stick with me.
Speaker: So yes, death is always hard for us as physicians or as nurses, a bedside provider, but especially in these circumstances are very, very hard to overcome.
Speaker: And I think that, like you said earlier,
Speaker: COVID-19 is not going away for now, but we might have future pandemics maybe.
Speaker: And I think this is an opportunity not only to think about what happens when you have a highly infectious disease that's causing a lot of critical illness, but also what are the opportunities that we have to really enhance how we communicate with families and how we practice empathy at the bedside, whether there is a pandemic or not.
Speaker: So I think that
Speaker: On one hand, it's devastating when we hear the stories and the moral distress that they have caused.
Speaker: But on the other hand, you also hear a lot of positive stories of teams that decided to make initiatives like Nobody Dies Alone and making sure that people were in the room with the patient, teams that basically got tons of iPads donated to them so they could FaceTime families for the patients and really a lot of effort in trying to
Speaker: to improve communication.
Speaker: But like you said, it's an opportunity maybe for us to build upon and keep working once COVID-19 kind of dissipates and we move on to our usual practice and not forget, I mean, that these are real challenges, whether we have COVID-19 or not, just that they were amplified by what we were living recently.
Speaker: Yeah, totally.
Speaker: One of the things we saw is the increase of spiritual disease, right?
Speaker: Because it was a way to see our patients.
Speaker: And even though in the past we assume perhaps the elderly are not going to engage in this type of visits, actually they engaged and we were able to provide services to our patients via virtual, like in 70, 80% of the time.
Speaker: So these are the things that of course show us that we are flexible, that we can
Speaker: you know, rise to the situation and also to understand the possibilities for the future.
Speaker: For example, advanced care planning discussions in the past were only face to face to do.
Speaker: And now they are being done also virtually.
Speaker: So this is an opportunity to understand how they feel.
Speaker: Perhaps it's better not to drive to the hospital park and then
Speaker: wait for the provider to have time to talk and then come back.
Speaker: Perhaps we can change our practice in many situations where only the discussion is needed and there's no physical to do.
Speaker: And then we can provide these ways to meet the patients where they are.
Speaker: I agree.
Speaker: So this last Memorial Day, the New York Times
Speaker: had a cover that was very poignant.
Speaker: They basically were recognizing that almost 100,000 Americans died due to the COVID-19 epidemic over the last couple of months.
Speaker: And they had a whole bunch of names and stories attached to that.
Speaker: I think that was very, very powerful.
Speaker: And I think it's the perfect segue to something that you talked to me a couple months ago at a medical meeting that really caught my attention.
Speaker: And I really wanted to hear more about
Speaker: which is the pause.
Speaker: So could you tell us a little bit what is the pause and how it originates and maybe dive into that?
Speaker: Yes, I'm happy to.
Speaker: So at the Cleveland Clinic, the first time we heard about the pause initiated by the medical team was when a fellow coming from Virginia Hospital that was trained with Jonathan Bartels.
Speaker: After a patient died in the ICU, he invited the team to stand up around the patient at the bedside and conduct a pause.
Speaker: And he said very simple words like, this is the time to honor this person, and he named the person with the name, and to honor him as a family member, as a loved one,
Speaker: and then honor our teamwork.
Speaker: And then he waited for some seconds and then he said, thank you.
Speaker: And the nurses loved it.
Speaker: And they say, how we can implement this across the organization?
Speaker: And then we did some pilots in some units.
Speaker: We did in some ICU units, we did in palliative care.
Speaker: And then we got feedback from the nurses and the doctors and the other providers, respiratory therapists.
Speaker: And then we tweaked, we did like a script for them because the first time is kind of awkward to do it.
Speaker: We are not used to do that.
Speaker: And then after we established this is going to be our script, we,
Speaker: start establishing the practice across the organization.
Speaker: And the good thing is we don't have numbers because I didn't want to make people to do a click in the electronic medical record because I think it's going to defeat the purpose.
Speaker: But I have many stories how this propagated organically in the system.
Speaker: So really, I think what it speaks to, Silvia, which I think is
Speaker: probably as important today as any day because a lot of these, when we say 100,000, it's just numbers, but we forget that each one of those is a human being and each one of those human beings had a lot of special stories, was important to a lot of other people and made a difference in the life of many people.
Speaker: And I think when you start thinking like that, the magnitude of 100,000 is really crushing.
Speaker: And I think that it's something that is important for us also when we are dealing with patients in the ICU is to take that time to pause and reflect that this is not just a patient who coded in room 22.
Speaker: This is actually a human being who means a lot to other human beings in many ways.
Speaker: Could you share with us the actual script that you would use in the Cleveland Clinic or that used by Jonathan for the pause?
Speaker: Yes, and first of all, I want to share that we end up doing with Michael Hebb and Jonathan and myself an app that you can find it, the pause for Android and iPhone.
Speaker: We have the script in many languages.
Speaker: So you know what we can do?
Speaker: We can take a pause right now to honor everybody who has died in COVID-19.
Speaker: How about that?
Speaker: That'd be great.
Speaker: I will change a little bit the script here, honor everybody.
Speaker: Let's take a moment to pause and honor every patient who has died during the COVID-19 pandemic.
Speaker: Everybody has been someone who loved and was loved, was someone's family member and friend.
Speaker: In our own way and in silence, let's take a moment to honor everyone.
Speaker: Let us honor also and recognize the care provided by every team.
Speaker: Thank you.
Speaker: Wow.
Speaker: Yeah, I can imagine how doing this on a regular basis can really help our teams in their grieving process.
Speaker: And I think it'd be almost, it's like the sixth stage of grief is purpose.
Speaker: and really recognizing that why we're there and that we're there to make a difference in somebody else's life.
Speaker: So how do you suggest teams that are listening to this today?
Speaker: So I'll put the link to the app also in the show notes, but how would you suggest that a team tries to implement this at their ICU, Sylvia?
Speaker: So what we did was finding a nurse champion and a physician champion.
Speaker: And then these two individuals were explaining the process and leading the first ones.
Speaker: And also to have the script printed, so available.
Speaker: So now with the app, it's very easy because you open the app and you have it.
Speaker: But at that time, what we did was
Speaker: piece of paper laminated with that.
Speaker: And then it started happening.
Speaker: And then many people have approached us to say, hey, we did this and it was amazing.
Speaker: And they tell the story.
Speaker: They tell what happened with the patient.
Speaker: And then they tell us how this works.
Speaker: So we did it this way.
Speaker: And then we started doing in the cold cards for the rapid response teams.
Speaker: and then in the operating rooms.
Speaker: So we train everybody in the operating rooms.
Speaker: And then one day, very interesting, somebody from IT came to me and said, Sylvia, thank you so much for the post.
Speaker: And I say, hey, but you are in IT.
Speaker: Why are you doing the post there?
Speaker: And then he said, you know, there was a colleague who lost his husband.
Speaker: And he came back and he was uneasy after the leave and he was sad.
Speaker: And then I gathered everybody in the office and we did the pause for his husband.
Speaker: And then after that, he was like connected again with work.
Speaker: And I was amazed because I never thought that that was going to be something done.
Speaker: You know, I imagine only in the ICU.
Speaker: And then...
Speaker: this person started to bring it up to the leadership and now the executive team every Monday name every patient who died in our hospital and they do the pause in the executive team.
Speaker: And the Joint Commission was here at the clinic last year and they found one of the 10 most impressive innovations.
Speaker: So I was like,
Speaker: impressed by how the impact of this practice got into the organization without our vision.
Speaker: I didn't know that was going to happen.
Speaker: No, and I think it speaks to the power it has, and I think it also speaks to what innovation is really all about, right?
Speaker: It's about adapting ideas or simple tools to make things better for everybody, and it doesn't have to be
Speaker: flashy technology, like you said, you have an app now, but you could do it with a piece of paper and the connection that it creates at the moment, right?
Speaker: Because it's also, I mean, I'm sure very powerful when it happens at the moment, I think is something that when you, when you share with me, I knew we were going to talk about this in the podcast eventually, but also something that trying to disseminate to as many programs as possible, because I do think that reconnecting the healthcare team, the ICU team with their purpose,
Speaker: is always important, but even so more I think in times like the ones that we're living right now.
Speaker: Can you just share other ways?
Speaker: I mean, you've shared, I mean, so it's been applied at the bedside in the ICU, in the OR, by IT as a team member, a family died by your executive team.
Speaker: Really, I mean, speaks to, it can really be applied to any situation where we're trying to recognize that a human being has died and what that meant.
Speaker: Is that correct?
Speaker: Yes, another situation that is also important is organ donation.
Speaker: When a patient changes from being a person that we are taking care of and we do the diagnosis of brain death or, you know, diagnosis of death with neurologic criteria, the heart still fit and the monitors are still the same.
Speaker: So it's very hard for families and for the team
Speaker: to switch from taking care of a patient to take care of an organ donor.
Speaker: So we also do this pause at that time, and I think help the nurses to switch minds.
Speaker: Now, like to close the relationship with the patient and then begin a new relationship with the organ donor and feeding what we are helping so many other people through transplant.
Speaker: So this is another application that we have done with the POS that has been very positive.
Speaker: And any comments, any experience with COVID-19 patients in particular?
Speaker: Well, I fortunately didn't have any patients with COVID that died.
Speaker: So I cannot speak for that.
Speaker: But it is a practice that is established.
Speaker: So I'm sure my colleagues
Speaker: that have experienced this with COVID have done it.
Speaker: Well, I really appreciate you sharing this with me originally, but also with our audience on the podcast.
Speaker: I think that it's definitely something that is worth emulating and worth propagating and making sure that other people recognize not only the patients who die, but also the work of the team around those patients, which is ultimately, I think,
Speaker: why we show up to the ICU every day as well.
Speaker: So one of the things we like to do in the podcast, Sylvia, as we close is ask our guests some questions not related to the topic that we were discussing just to tap into their wisdom.
Speaker: Would that be okay?
Speaker: Yes, of course.
Speaker: So the first question applies to books.
Speaker: And I was curious to know there's any book or books that have influenced you the most or that you have gifted most often.
Speaker: Oh, so I liked Outliers.
Speaker: It's a book from, what is this author, Malcolm?
Speaker: Malcolm Gladwell, yeah.
Speaker: Gladwell, Gladwell.
Speaker: I think Outliers helped me, and I like to give it to young people to understand that
Speaker: you have to invest time in order to do your best.
Speaker: And things don't happen because you're lucky.
Speaker: There's some things that are luck, but I always think that there is your own effort and investment.
Speaker: And then I really like the tipping point that I'm reading right now to understand how things can be, you know, moved along and how ideas can be transmitted from one people to other.
Speaker: like helped with social changes that are positive to everyone.
Speaker: So I think this author, I love to read him.
Speaker: Well, clearly, I mean, he is a brilliant mind and I think a great teller of ideas, right?
Speaker: So I think that both books, I think, have a lot, I mean, that are applicable to what we do, I mean, in life in general.
Speaker: So I will include links to those.
Speaker: I also will include a link to the book you mentioned earlier, which is When Breath Becomes Air, which I think also is a beautiful read, very powerful.
Speaker: I mean, obviously a very sad story, but like you said, with a lot of opportunity to learn really about life also through that experience.
Speaker: The second question, Sylvia, is what is something that you believe to be true in medicine or in life that most other people don't believe or at least don't act like they believe?
Speaker: I think I would say that empathy is power and keeps us connected to our own purpose.
Speaker: When we choose to serve others as physicians, as nurses, as a healthcare provider, we are committing to help others where they are, understanding their situation.
Speaker: So I think empathy is
Speaker: the most important thing to keep us connected and I think help us to be, to have less moral distress.
Speaker: Yeah.
Speaker: And I think that we were talking about this earlier before we started recording, but I think it also came throughout our conversation in the podcast, but I think that also empathy towards the people who work with us in the ICU is very powerful.
Speaker: And I think that understanding where a consultant, where a CT surgeon stands, where a nurse stands, where they're coming from and understanding that there may be a lot of things that we don't understand that day that are going on in their life that might be impacting what's happening in front of us.
Speaker: And I think having that recognition, like you said, I mean, is the first step in really making a difference in somebody else's life.
Speaker: Yes, totally.
Speaker: So the last question is, uh,
Speaker: related to what would you want every intensivist who's into this podcast to know could be a quote, a fact, or just a comment?
Speaker: Perhaps I will talk about the pause.
Speaker: I want every intensivist to know that the first time may be awkward.
Speaker: We are not used to it.
Speaker: However,
Speaker: I want to encourage every intensivist to try it at least one or two times.
Speaker: I think the power of this silence of centering us as a team, but also as an individual, because it's in silence, so each person can do it by themselves and in their own way.
Speaker: I think it's very powerful to give us breath in our busy day and
Speaker: And to let our emotions go away, to flow.
Speaker: Sometimes we grow in medicine, like we have to be strong and help others.
Speaker: So we have to take care of ourselves.
Speaker: And I think the pause is one of the things that help us to center ourselves again after a death of a patient.
Speaker: And I think that's a perfect place to stop.
Speaker: I want to thank you for your time and sharing your expertise and also sharing the pause with me and our audience.
Speaker: And I definitely look forward to hearing stories of people who have implemented it and sharing those stories with you as well.
Speaker: Silvia, always a pleasure.
Speaker: Hope to see you soon again and to have you back on the podcast.
Speaker: Thank you so much for inviting me.
Speaker: This was an honor.
Speaker: Thank you for listening to Critical Matters, a Sound Critical Care podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
Speaker: Sound Critical Care is transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
