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Moral Injury: Supporting Individuals and Teams
Moral Injury: Supporting Individuals and Teams
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And so I'm going to start by just saying that, acknowledging that what we do is hard in the ICU. And we've been through a lot in the last three years. But even beyond that, we work really hard and we take care of very sick patients. And it's inevitable that when we're caring for patients and their families, and when we're working in large teams and have consultants coming into the ICU, inevitably we're going to have times where we experience intense personal challenges, professional challenges, and there's a great deal of emotion that goes into what we do. And I think that part of finding solutions for when we suffer from moral injury is acknowledging the existence of it. So I have no disclosures. I have no conflicts of interest to disclose. And I'm going to start with a case that I think is going to resonate with most everybody in the room. So a 51-year-old man has been hospitalized in the ICU for three weeks with COVID-19 pneumonia and ARDS. He's suffering from persistent hypoxemic respiratory failure. He's vented on 100% FiO2. He's sedated. He's on neuromuscular blocking agents. He's proned. He's receiving inhaled nitric oxide with O2 sats that are consistently in the 80s. The ECMO team came by and they said he's not a candidate due to his age and the duration of his illness. And his family is demanding that everything be done. He's currently full code. And nursing is expressing frustration that he's suffering and they're actually using some morally charged language saying that they feel like we're torturing him. This probably doesn't sound familiar to anyone in this room, right? Now, you're also distressed because you're a human being. You're distressed over his unrelenting illness, the fact that despite your best efforts, you're not able to rescue him. Nursing is pushing you to make him DNAR and comfort care. You're worried about the suffering that you might be causing him through the interventions that you're offering. There's limitations on visiting hours, which has caused tension with the family. He's dying and you can't let him in the ICU and you can only let certain members in at certain times of day. And then you've just got fatigue from three years of COVID care. There aren't people banging pots and pans at 7 o'clock at night hailing the healthcare heroes anymore. Now they're pointing at you and saying, you did this. You caused my dad to be so sick. So I don't know about you, but I do a lot of medical humanities work. And so I always think about this painting from Edvard Munch, 1895, called The Scream. Because this is sometimes what I feel like when I'm in the ICU doing patient care, is I feel like I'm completely overwhelmed. And despite my best effort and energy and compassion and empathy, I feel like I'm at the end of my rope. So my objectives for the talk today are to define ethical challenges that clinicians encounter in medical practice that can impact on our well-being, to explore the link between moral distress and burnout, and how we can reduce burnout and enhance wellness. And then discuss strategies for reducing moral distress in sporting teams. And I'll be honest with you, the first two are going to be a little bit evidence-based as we talk about the data. The last one is going to be some tips that I can offer you that you can leave the room with today and bring back to your teams at your institutions that may or may not be evidence-based, but certainly work to help enhance wellness. And if there's one thing I want you to be able to do at the end of this talk, I want you to be able to leave with practical tools that you can use for your team members and yourselves. So first of all, what is moral injury? Well, moral injury is the inability to act according to an individual's ethical beliefs. And what happens is you have a moral event or a moral dilemma that you're experiencing, and you feel like you know the right thing to do. And I use the term right in quotes. But you feel very strongly that you have a moral compass that points due north, and you know the right thing to do, and you know how to act. And you're feeling like, for one reason or another, you're being prevented from acting in that way. And it results in injury or a moral dilemma. What do I do? And over time, if you're not able to address it, it can cause moral failure. You can feel like you have failed yourself. You have failed your profession. You have failed your patients. And it can be completely overwhelming. And so if you are familiar with the Thomas and Kilman moral, excuse me, index for communication from the 1970s, I adapted it here a little bit. But what you'll notice is that on the x-axis, you've got cooperativeness. On the y-axis, you've got assertiveness. And there's really four options for how you can approach patient care in situations where you feel like you're in a moral dilemma. You could certainly be very uncooperative and unassertive and withdraw. And we've all done that at times in our careers, right? So we're avoidant. We don't go into the room. We don't have that family meeting. You could be more cooperative, but equally unassertive, where you acquiesce. They say, I want you to do this for my mom or my dad. And you say, you know what? I don't have an enemy today. Yes, I'll do it, right? And we've all done that before. Conversely, you could be less cooperative, but very assertive and be competitive. And we certainly have done that as well, right? So no, I'm sorry. We're not going to do dialysis. It's not medically indicated. I understand that this is what you want, but it's not something that I can do. And that doesn't always improve relationships either. We'd like to be in this green zone where we're trying to resolve. We're finding ways to collaborate. We're finding ways to compromise. We're finding ways for everyone to leave the table, as it were, with the conflict resolved and feeling like even if it's not what you wanted, it's something that you can live with. But the reality is we don't spend a lot of our time in that resolution phase sometimes, especially with these intensely morally charged and injurious moments. And so you can imagine that if you're not in that green zone, you can have a lot of feelings bubble to the surface. You can feel moral emotions, anger, frustration, indignation, resentment. You can have feelings of guilt and sadness, feel regret for not acting in a certain way, or even feel powerless that you want to be able to act and you simply don't have the ability to do what you feel is right. And it creates this crescendo effect where the moral event or moral dilemma results in the injury or distress and leaves this residue, this moral residue on your soul, really. And it decreases the threshold for future moral injury so that reminders of prior events cause greater moral injury the next time and stronger reactions in you. And so colleagues, Beth Epstein and others, looked a few years ago at the top five causes of moral distress among health care professionals. And I think these will all resonate with you. Number five was continuing to provide aggressive treatment for a person who's most likely to die regardless, and no one is willing to withdraw life support. Number four was being unable to provide optimal care due to pressures from your institution or insurers about reducing health care costs. Number three was feeling pressure to order or carry out orders that I considered unnecessary or medically inappropriate. Number two was following the family's insistence, so being in that acquiescence sort of space, following the family's insistence to continue aggressive treatments, even though I believe it is not in the best interest. And number one was witnessing other health care providers giving false hope. So with undying respect for my oncology colleagues, those oncologists come in and say, hey, guess what? Your cancer's cured. And I'm thinking to myself, well, the chemotherapy caused refractory ARDS, and you're going to die of critical care. And telling the family that they no longer have active cancer probably wasn't the right move in this moment. And it's going to cause tension down the line. And the consequences can be really powerful for the patients and their families, for the profession of medicine, and for ourselves. So for the patients, we all know about the data looking at PTSD, complicated grief, anxiety, depression. For the profession, there's loss of trust. There's loss in faith in us, which causes conflict in partnership. And then for ourselves, you think about things like compassion fatigue and burnout. And if you were to look for some of those behaviors that are concerning for moral distress, you may find that you have experienced some of these yourselves. Depersonalization, avoidance, fatigue, maybe being short-tempered, having job dissatisfaction, and even loss of purpose. And I'll be honest with you. In the last talk, there was a comment about the attending saying, I don't believe in burnout. I don't have burnout. And I'm not sure I buy it. That's great. But I'm not sure I buy it, to be honest with you. I was on service in the ICU a couple of weeks ago. And on day one, I found myself saying, I don't want to be here. And that's never happened to me before. And all of a sudden, I was scratching my head and saying, huh, I'm burned out. What am I going to do about it? Because these symptoms really are what drives compassion fatigue and burnout syndrome and ultimately results in people leaving the profession of medicine in whatever your role is in health care. So how do we fix it? Well, the problem with fixing moral distress is that it's subjective. As an ethical phenomenon, it's very subjective with numerous causes and effects. It's going to be different for each individual. And so I would love to be able to stand up here and say, do yoga and meditate. Read a book. But the reality is, that may work for me. But it's not going to work for you necessarily. And so these sort of one catch fits all solutions really isn't going to cut it. So we have to have ways that we can try and improve things for everyone across the board. And so what can we do? What can we do to build empathy, to help think about patient narratives, to improve on our compassion, to be more resilient? What can we do to support each other? So this is the part of the talk where I go through some things that we've implemented in our institution and hopefully give you some pearls and tips that you can use to take back to your institutions to help support each other and support yourselves. So we can cultivate compassion and humility. I'm going to talk about each of these. We can engage in the medical humanities. We can create more positive work environments. We can engage in intentional processing. And we can do things like grieving rounds and real-time debriefings for our experiences to try to offload some of the distress. So how do we do each of these? OK. So why am I going to define compassion and humility? You all know what compassion is. You all know what humility is. That's great. But not everyone does. And I think it's important as a starting point that we be able to define it for individuals. This is what compassion looks like. This is what humility looks like. And this is a teachable skill. These soft skills are teachable. These are not something that you're born with. And it's not something that you have all the time. You have to work for it actively. So compassion is the emotional response to another's pain or suffering that involves an authentic desire to help. It's why we went into medicine. It's why we went into health care. It has a powerful effect on the receiver. But it also has a tremendous effect on the giver as well. And so it can sustain you by trying to enhance your compassion. And the Dalai Lama says, if you want others to be happy, practice compassion. If you want to be happy, practice compassion. Humility is a recognition that what's happening to the patient in the bed and their family by extension isn't happening to you and your team. And that while you may be struggling, what they are experiencing, their narrative, what's happening in their shoes is so much worse. And we need to find ways to be able to partner with them, even when we feel so strongly that what we're being asked to do is antithetical to what we believe in our core. And so I really try to live by this mantra that's been very helpful for me. If it's meaningful to you, it's meaningful to me. I may not agree with you, but I'm going to spend time trying to understand why you're asking for what you're asking for, why it's so important to you, what underlies that request, what's your narrative. And I'm going to try to understand your suffering. And so there's a couple different ways that we can do this. But the one that I really want to talk about is medical humanities. And Medical Humanities is not just reading a book written by a palliative care physician. They have great ones. But that's not what Medical Humanities is. It's an interdisciplinary field that encompasses a lot of other fields, including literature, ethics, sociology, psychology, medical history, a number of other fields. And the idea behind it at its crux is that by integrating arts and humanities throughout medical education of our trainees and our colleagues, health care team members can learn to be better observers and better interpreters of what our patients and their families are experiencing and what we are also experiencing. And by being more closely observant, we can actually build empathy and compassion and build humility and improve on the quality of teamwork. And that ideally, these experiences are actually quite enjoyable. So it's not just for the patients. It's also for us. And it can promote health and wellness, which is really what we're looking for. So just a little bit more on Medical Humanities. They help us pause, take a step back, and try to think more deeply about what's happening to our patients as human beings. It tries to disrupt or change the bias that we experience and some of the beliefs and assumptions that we will draw on our patients and their families in terms of what they're thinking. And forces us to pause before we act. And then we engage with this complexity and the ambiguity of different moral perspectives that may be out there, what I believe, what you believe, your experience, my experience, and get past the surface and dig down deeper to try to understand what human beings are experiencing during times of illness and suffering. And then it really just encourages awareness that there is potentially multiple moral perspectives that exist. And that in a given scenario, you may have a different moral perspective than me. But it doesn't invalidate your moral perspective just because I disagree. You can have that tension between different perspectives. So if you were going to do some Medical Humanities work in your institution, I might suggest literature rounds. And the way you would do this is you identify a dedicated time and place. You have staff bring any form of Medical Humanities they want to share. It doesn't have to be a novel. It doesn't have to be a nonfiction piece of literature. It can be a poem. It can be a song. It can be a work of art like The Scream, where you can show it and say, this is what I'm feeling at this moment. It can be anything that you connect personally with that you can also connect to your patients and their families. And then you use the power of the storytelling to understand the medical world and gain insights into your patients and their families and yourselves. Now, you do not need to parse out a poem. You don't need to read it line by line and try and understand the iambic pentameter or the number of words on the line or where they chose to put a punctuation mark. This is not an English class. You can really just have people comment and share and then just let it be out there. You don't even necessarily have to discuss what they shared. You can simply just let it percolate. And just allow it to create meaning for ourselves and our patients and hopefully create more compassion. So we do literature rounds when I'm on service at the end of every week and I have everybody bring in something and we just spend some time sharing something that brings us joy. Well, how can we also create positive work environment? I've split these into some on rounds and not on rounds or outside of rounds. And on rounds, I like to introduce a non-medical question of the day. This is super easy. It just creates a nice, safe work environment and a welcoming space. It's totally non-medical. It's right brain focused. If you could meet one person in history and have dinner with them, who would it be? Go. What's your favorite book? What album did you listen to most recently? Do you like to listen to music through digital? Do you like LPs? You still have a cassette recorder? You can ask any question you want and it's just to get things stimulated. And you wanna be very inclusive of all of the team members. So if you're standing on rounds and you've got nurses and pharmacists and respiratory therapists, ask them too. It's not just for the providers. And I've actually had situations where I had families on rounds who participated or even a patient who was awake in the ICU and said, hey, I have a comment on somebody I'd like to meet in history. And it was so fantastic because it created this connection, this human connection between us and the patient. The other thing I like to do on rounds is challenge my team members to go find one thing about their patient as a person and bring it to rounds the next day. And when we're presenting that patient or talking about that patient, we share that one nugget of something personal. Hey, I'm from Philadelphia. Hey, this guy loves the Phillies. He goes to games every year. Or this patient has a dog that's her best friend. Learn something about them that helps you connect on a human level. It makes a huge difference and it really helps you not only be more compassionate, but it makes you feel better about the work that you're doing. And then very similar comment to earlier, food soothes the soul. I buy coffee for the entire ICU at the end of every week, every time I'm on service. And the smile on people's faces when I come back with 20 coffees for 20 different employees and hand out coffees to everybody is amazing. I'll tell you, it takes a long time to order it on the Starbucks app. But once you get it ordered, people love to get their nonfat soy caramel macchiato. It just makes their day. You can buy cookies or donuts or something else. And really it does go a long way to make people feel that they're being seen. So those are some ways to enhance the positive work environment. What about intentional processing? There's a few ways that you can do some really thoughtful processing. One is journaling. And I know that some of you are gonna be like, this is not for me. And that's totally okay. Journaling is not for everyone, but there is something about what happens in the brain in terms of processing experiences when you put pen to paper. So don't journal on a computer, journal on paper. We actually hand out, I run the humanism and professionalism curriculum for our fellows at Penn for medical critical care and pulmonary medicine. And I give them a journal at the beginning of the year. And I ask them throughout the year to just scribe a little bit when they're feeling something. Don't talk about the medical aspects of what happened and what you changed on the ventilator. But when this patient died, what did you feel? When this family got angry, what did you feel? What was your response? What have you been thinking about since then? And it's a really great way to kind of offload some of that distress that's in the mind. We also implemented this pause strategy where if a patient dies the next day when you're passing the room that they died in, you stop and pause on rounds and you just spend a moment to acknowledge the existence and the death of that patient. You just spend a few minutes talking about them, talking about your experience with their death and acknowledging that they were here because it's so easy when patients die and a new patient comes into that room to just move on. And it's a really cathartic moment for us as healthcare providers to say, man, he died and that was really hard and I wish we could have done more but he was such a kind man and I'm so thankful that I had an opportunity to care for him. Similarly, there's this idea of the honor walk which is a mechanism to honor deceased patients where you actually intentionally have staff pause and stand along the hallway as the EMS folks are bringing the patient's body to the morgue. So in the ICU, as they're removing the patient's body from the room and they're gonna be exiting, you all stand and you just take a moment to stop from your work and acknowledge that this patient has died. Very, very simple to implement. You just ask everybody to stand there and just be present. Let's talk a little bit about grieving rounds. So grieving rounds is a safe space to process emotions related to ICU care experiences. And these are dedicated, consistent rounds that you do that are in a protected time. And so if you're gonna implement it, you really need to implement it in a way where you ensure that there is a protected time and space to do this. Real-time debriefing is a little bit different. Thank you. Some experiences need to be addressed in the moment and just can't wait for a dedicated grieving round session that might be every two weeks or every month. We do it for our residents every two weeks because they rotate every two weeks and we do it for our APPs and our nurses in the ICU once a month. You may not be able to wait that long. And it's especially important after morally charged events or really complicated outcomes that you maybe need to debrief in that moment. So a few fundamentals. Every death or emotionally challenging experience deserves some form of a debrief. Sometimes it may be just pausing to acknowledge the humanity of the patient, but other times it needs to convene a group where you really talk about what went well and what could have gone better. They don't have to be extreme events. It could just be a patient who died after hours of care at the bedside and you're feeling that loss. What was the point of all that I did over the last four hours caring for this patient? He died anyway. I need somewhere where I can unpack that. You want to include all members of the ICU team, not just physicians or providers at the bedside. And think about who might have been involved longitudinally over time. Try not to debrief in the hallway on rounds. You really want a dedicated safe space. And so if the experience is really significant, sometimes I'll actually stop rounds in mid rounds in between patients and say, we got to debrief. We got to move into a conference room. We got to think about this a little bit more. You can introduce screening rounds and real-time debriefs as an open, safe space for the individuals to participate in. Try to normalize and validate emotions that are felt during their rotation. And also identify some of those maladaptive behaviors that I described earlier and link them to ways to bounce back emotionally. And then modeling how to support families in end-of-life care and maintain your own resilience when you feel so strongly that you have objections to what's being asked of you is really important. And so trying to, again, understand the moral framework of the individual and why their perspective is different than yours, but also not necessarily invalid compared to yours is important. Start by addressing emotions and feelings. After people have shared, you can start talking about some of the medical aspects, what went well, for example, to ensure a psychological safe space. You want to start with the positives. When you get to the things that could have been done better, try to avoid some of the language like mistakes or what went wrong and use more positive-focused language. What might we do differently next time or what are our opportunities for growth? Don't point out individual errors. You want to try to focus on systems and not point out individuals. And then promise to follow up if you think there's opportunities for quality improvement and provide resources for people who are still struggling, whether that be palliative care, chaplains, the employee assistance program, et cetera. And then lastly, you're breaking down a lot of emotional walls. You've got to build people back up at the end. So always end on a high note. Talk about positive experiences. Talk about the things that we can do for each other. Even when we feel like there's nothing we can do for a patient medically, we're still there for them and caring for them. And create some language that you can use to end on a high note. What are you going to do in the next 24 hours to bring joy to yourself? Or what are you looking forward to in the coming days when you have a day off from work? It's really helpful to get that positive energy. I'm not going to spend a lot of time on this slide, but it's important that when you go back to your institutions, you find leaders who are going to support you within systemic solutions. It's not just what you do at the individual level. You have to have institutions supporting you as well. And you can look at this slide and take a screenshot of it. And later, think about how you might ask for some of these things. How might you ask for policies and decision-making tools that take some of the moral weight off of you when you're trying to make choices for patients? How can you ensure that they normalize emotions and feelings that people are having? So in summary, I would say that moral distress occurs when people feel impeded from acting according to their ethical beliefs. Repeated insults can leave this residue that causes negative impacts for future patient care. Over time, moral distress can result in burnout that can be damaging to our patients, profession, and staff. And that you need individual actions, like the ones I described, in concert with system-based solutions that can help minimize the damaging effects of moral distress. And because I'm a medical humanist, I'll just end with a quote. I love quotes. This is from Edgar Allen Poe. The boundaries which divide life from death are at best shadowy and vague. Who shall say when the one ends and where the other begins? Thanks so much, everybody. Thank you.
Video Summary
The speaker discusses the concept of moral distress in the healthcare profession, particularly in the ICU. They explain how moral injury occurs when healthcare providers are unable to act according to their ethical beliefs, resulting in emotional challenges. They provide a case example of a patient with COVID-19 who is suffering from severe respiratory failure, and the healthcare team is struggling with the decision on how to care for the patient and address the family's demands. The speaker emphasizes the importance of acknowledging and addressing moral distress. They discuss strategies to reduce moral distress and enhance well-being, such as cultivating compassion and humility, engaging in medical humanities, creating positive work environments, and practicing intentional processing through activities like journaling, grieving rounds, and real-time debriefings. The speaker highlights the need for both individual and systemic solutions to address moral distress and prevent burnout in healthcare providers.
Keywords
moral distress
healthcare profession
ICU
moral injury
COVID-19
respiratory failure
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