SCCM Resource Library-Humanizing Intensive Care

Video Transcription

Ladies and gentlemen, please welcome Dr. Ruth Kleinpell.  Good morning. Thank you so much for joining us. It is my pleasure to introduce Dr. Nicholas Ninn,  the presenter of this year's Aki Grenvick Honorary Lecture. Dr. Ninn is the medical ICU coordinator at Hospital Español in Montevideo, Uruguay. He is a member of the Red Ventilia,  QC, and Latin America Intensive Care Network, LIVIN Networks. Dr. Ninn is also an intensivist with a PhD and post-PhD at the Getafe Hospital in Madrid, Spain.  This morning, Dr. Ninn will present the Aki Grenvick Honorary Lecture titled, Humanizing Intensive Care. Please join me in welcoming Dr. Nicholas Ninn.  Good morning, everyone. It's a pleasure to be here. I want to thank the organization,  especially Gloria, Marie-Cruz Martin, that now is the first woman of the president of the  Ibero-Pan-American Society, so congrats to Marie-Cruz. I'm representing now the Project OUCI. It starts six years ago with the vision of the director, that is, Gabriel Hera,  that is now with us. And there are a lot of members of the Project OUCI, so I'm very, very thankful to be here. Let's start.  Well, that's why we are here in this presentation. I will talk in the next minutes in these key points, talking about the patient, family, the professional, and finally I will show  what is our project about. The definition of humanization is not new. More than 100 years ago,  this is a very nice book from Francis Peabody, The Care of the Patient. She told, in a quote,  that the treatment of a disease must be completely impersonal, but the treatment of the patient must  be completely personal. In the same period, this is another wonderful book from Professor Osler,  The Master Word in Medicine. He told us that in our daily life, tenderness and consideration to the weak, so to be more human with our patients. What's humanization about? There  are a lot of definitions, a lot, plenty. Something human, familiar, it includes the promotion of health and the process of death, so it's very wide, the definition.  You know now, humanization or humanization in the ICU is fashionable and it's important, that now it's a trendy topic and it's very important to start thinking about humanization.  And now we must consider it an ethical issue. So that's what are saying some people like  Diego Garcia, that she's a philosopher. So we must, it's not the same to be a human being or living humanly. You know, in our career as doctors, nurses or professional staff,  we have a lot of technical strengths, but we have fewer communication skills, less emotional skills and very less spiritual skills. So we need to improve not only the  technical skills in our career. Communication is extremely important. We learn sometimes to  give bad news, but we must be more, more leaders. We must have more emotion, intelligence in our  daily life. We must work and learn to work in teamwork, because most of the year, errors and  conflicts in health, they're, as you know, from bad communication. You know that good communication  has a positive impact, even when the news is bad, and poor communication have negative impact,  even when the news is good. That is extremely real. So it's important to change the question  to their patients or their family. And the question must be, what matters to you? To change the paradigm of the communication with the families and the patients. You know, we have  three lines of studying in the Project UCI. One of the most important is the patients always.  We do this for the patients. You know, I have a lot of friends of mine that,  doctors or nurses, that became patients. So there is a Chinese proverb that says, no one can be a good doctor without first having been ill, or our families too, because  we sometimes become patients from our families.  What the patients expect from us, how they see us. You can see these are photographs from some  patients from Mexico, D.C. They see shadows, dark, they see us in front of them, but it's very  important to think about what they see us. You know, sometimes there is a dissociation between  what we want to hear from our patients, that we want to hear an account of symptoms, and the view  is in completely opposition that what patient wants. The most valuable, they think, is the  doctor who listens. So there is a dissociation between what we want and what the patients or family needs. What do patients want? You know, to be treated with dignity and respect.  The doctors and the nurses that have easy talk, take your concerns seriously, enough time with them, and that we really care about them. I will show you a video.  We have a juvenile onset diabetic with poor circulation and diabetic neuropathy. As you can see, these are diabetic ulcers with lymphedema and evidence of gangrene.  Questions? Any osteomyelitis? None apparent, although not definitive. Treatment? To stabilize the blood sugar, consider antibiotics, possibly amputation.  What's her name?  I was just wondering the patient's name.  Marjorie.  Hi, Marjorie.  Hi.  Yes, thank you. Let's move on.  This is a wonderful movie. You know, last year, we have done a little research  that we asked this question, if the doctors and nurses that are every morning with the patients  knows their name. Only 40% of the doctors that every morning in the ICU see the patients, know the name of the patient, and 70% of the nurses.  So it's a very simple question, but sometimes it's very important for the patients and for the family, this simple question. And it's about empathy, you know?  People will never forget what you made them feel.  That's a quote for Maya Angelou.  Sometimes we treat our patients like it's a game.  Sometimes we treat our patients like in this book, less than human.  Sometimes the patient feels that they're in a nightmare in the ICU, or even worse, after discharge, they have a lot of nightmares about when they were in the ICU.  So we will talk a few moments from dehumanization.  You know, a patient with ender to the hospital is not a person, it's a patient. In medicine, always, sometimes we treat the patient slightly less than human,  unintentionally, because it helps us to be protected, especially in the ICU.  You know, this letter to the editor that, so yes, we dehumanize patients,  but this is inevitable, adaptive, and even morally and psychologically acceptable.  So we recognize that we dehumanize patients sometimes.  How we do it?  With mechanization.  We mechanize our patients with empathy reduction and with moral retreat. That's the way that we unintentionally dehumanize patients.  Also, you know, what's humanization, and the opposite is dehumanization.  It's very important, the word that, or the concept of personal journey, that they will, I will,  I will have a photograph that we are frozen in the personal journey when the patient and the family are in the ICU. You know, this is the personalization chamber.  We, the patient enter with a lot of memories, values, aspirations, and then it's only a patient in the ICU.  I woke up in intensive care.  My eyes was falling shut, I couldn't see.  My jaw was wired closed, and there was a hole in my throat, so I couldn't eat, I couldn't speak, I couldn't drink. I couldn't drink.  And there was a machine forcing air through the hole in my throat, so I couldn't even breathe for myself.  But I could hear everything.  And I searched through all the noises of a busy intensive care unit for any sign about what was happening or likely to happen to me.  And then a machine would beep loudly. I couldn't see, and I didn't know what it was. And I thought that maybe I was going to die.  But somebody would come, and they would reset the alarm and move away silently.  The doctors would come around the bed, and they would discuss my case in great detail with each other  in a language that I didn't understand. And then they, too, would just quietly go away.  And at night, nurses would come, and they would attend to my, the IV lines that fed and hydrated and medicated me, and they would take notes, I suppose, and read things.  And they attended to my physical needs with skilled efficiency, but they never saw, they never acknowledged my physical needs. Emotional needs, except for one special nurse.  Every time he came in to look after me,  he would lean close to my face and put his hand on my shoulder.  And I could see through the slits in my eyes the outline of him, and he would call me by name.  And then he would tell me what he was going to be doing that day.  And then he did something that not one other person did for the three weeks that I was on life support.  He talked to me like a human being.  He would talk about everyday things, as he went about cleaning my wounds, cleaning my body,  you know, washing me, changing my clothes, checking my IV lines. He would talk about things like what kind of a day it was outside,  or who would come to visit me while I was asleep. He talked about common, everyday things.  And it didn't take him a moment longer than it might have taken otherwise. People are so afraid that if you make a human connection with a patient,  that it's going to take too much time. It took him no extra time.  And yet, 20 years later, it was 20 years ago that I had a multi-trauma accident that nearly killed me and kept me in hospitals for 17 years.  But I remember him. And every time I speak, I tell the story of this nurse, this wonderful man, and how much his touch that didn't hurt, that wasn't efficient,  how much that meant to me, how much telling me what the weather was like outside, or telling me a little anecdote about something that was on the news,  anything like that reminded me that I was more than a broken body.  And I will never forget him. And it's 20 years.  And I still feel the gratitude of that more deeply than I can express to you.  As you know, the patients will remember how we make them feel. This is Kathy from Australia, and he's one of the patients in the Project OC. So we lost the personal travel.  The patient lost the personal travel when they are in the ICU, and the family also, because we are connected, we are continuity, and this continuity is stopped.  Like in this photo, we are stopped and frozen in this journal when we are in the ICU or discharged in the hospital. You know, the most common torture methods are sleep deprivation,  isolation, and cold cells. And sometimes, unintentionally, our patients can suffer  this kind of extreme torture methods. Extreme.  And in the opposite, we have this imagine, this home. This is a definition from Wikipedia, no? It's a place, calm, that we feel secure.  You know, when you think how people sleep around the positions, you know, these are the most common sleep position.  The soldier position is only 8%,  and if you have a couple, you have another kind of position at bed.  So these are the normal sleep position.  I couldn't sleep in this position. It would be impossible for me. If not, I'm extremely sedated. It's only 8% that are single sleep in this position.  So another important thing is the patient welfare. The control of the pain, the attention of the psychological and emotional aspects,  and the psychological discomfort also. So it's very important to focus in the patient welfare when they are in our ICUs.  Patient autonomy, you know?  Patient autonomy, you know?  Now, millennials and centennials are extremely connected. We are extremely connected. So in the next years, to be connected in the ICU will be extremely important,  to have the cell phone or whatever. But now we are extremely connected, and that is very important, and will be more for our patients or for our millennial or centennial patients  that will be in the future. Connection.  Another important thing is how much noisy we are, you know? The noise of a hospital is compared to a factory.  We are extremely noisy.  This quote from Florence Nightingale, 150 years ago. She said that unnecessary noise is the most cruel absence of care which can be inflicted either on sick or even unwell.  So not only affect the patient, but could affect us working in a very noisy situation.  You know, the hospitals are not so quiet, and the ICU with the alarms are not so quiet also.  So noise control, very important.  Light control.  You know, we must promote natural light in the day, and we must promote that the lighting during the night will be stopped  or have less light in the night so the patient can have some comfort about lighting. So noise and light are extremely important for the welfare of our patients.  And you know, there are a lot of papers with the impact of having bad sleep  besides and across some physiological aspects like the brain injury or whatever. So it's very important, the sleep for our patients.  What about the family? There are lots of communications and papers talking about the family, and it's one of the most important topics in the ICU.  The presence and the participation of family members in the intensive care in the United States is very usual, but in Latin America it's not so usual.  There's a lot of things to improve in this particular point.  As you know, to have the family in the ICU have a lot of advantages. It could be like this paper that they're making the preventive in ICU acquire weakness,  but there are some papers about delirium or psychological detriment. So it's very important to talk about and to think about the presence of the family.  But you know, in this photo you don't need a paper or a quantitative analysis because when you see what happens with the face of our patient,  what enter the family, it's only to see what's happened. And always in the ICU beds, you have some photos of kids, of family members that they are young.  So what about children?  Why always in a lot of units children under some age are not admitted?  And there are some important for the fathers, grandfathers and whatever.  So it's another thing to improve or to talk about or to resolve in the future. If children will be or not admitted to visit their families because they are only in photos.  We have done last year a study of what about the culture of humanization in Latin ICUs.  We have a questionnaire of 71 questions with a lot of dimensions  about analyzing the culture of humanization.  And we find in nine countries that 36% of the ICU have some time of training of humanization.  92% agree that it's very important to have another skills. Family visit flexibilities was in 75% and we have some dimensions very weak like you see in red.  Children only is allowed to visit in 20%.  The psychological support of the patients or the staff is very poor.  Early mobilization protocol is very poor. Post ICU care protocol only in 12% so we have a mean of 45% of positive response.  So we must do a lot of things to improve the culture of humanization, especially in Latin America.  What about us? What about the stress of the situation? What about us? What about the stress we are having, the burnout?  That is for me one of the most important topics to explore in the future.  This is a very nice paper in 1974 that told us who is vulnerable to the burnout.  Who is vulnerable to the burnout, the dedicated, the ones that need to give and some preventive measures  like training programs, limited number of hours, etc. So it's a very important paper that never, nothing changes in this paper.  You know that the stress would be good, bad or chronic.  One of the most stressful situation for us perhaps is this one, both. One is a very difficult airway intubation. It's an extremely stressful situation.  But we have two stressful situations. First, this one and then we should talk to the family.  After this stressful situation, we have another emotional situation, even if the news are good or are bad.  So double stress situation we are having when we are in this kind of situations.  You know, which is the burnout adaptation? First, the emotional.  Our family, the family isolation and then the social isolation.  We have lots of colleagues that are in this situation.  You know, burnout is more complex, as you know. It's not only burnout.  There is bore-out also.  That is the lack of challenges and the loss of the interest in work. And we have also the compassion fatigue.  So it's more complex than only burnout. I think bore-out is extremely important and compassion fatigue also in these three stressors that we are having.  You know, what are the consequences of the burnout? The medical error, the low patient satisfaction, the work absence.  We have 30% of work absence in nurses in Latin America.  Emotional distress and family dysfunction.  The burnout, there are a lot of papers with the association of burnout and medical errors,  burnout and decrease in safety culture.  What are the causes of burnout? One of the causes is the work overload. We are sometimes extremely work overload.  And you know, sometimes we are extremely tired.  Especially the youngers, the residents, the nurses that work some 12 hours per day.  We have done this study, published in Critical Care in 2018, looking about the practice of intensive care in Latin America. It was a survey of academic intensivists.  It was a survey against doctors.  What we found that 50% wants to leave the specialty.  And there was a link in not so good work conditions. In very few countries, the doctors consider that they have good work conditions.  And you know, the future projections from the ICU intensives in Latin America is to leave the night shift and to be intensivist until retirement only in the 44%.  I don't know in the States, but this photo is very bad for intensivists in Latin America.  You know, which physicians are more burned out? We are in the first place.  Who works more hours?  We are in the second place.  Which professionals are more overweight?  We are in the fourth place.  So, it's a little bit worrying that we are in the first place in these dimensions or topics.  That's why it's important to think about what action plans we must do in our discipline.  Another important thing, it's about self-care stuff, you know?  You know, we are the ones that have fewer visits to the doctors.  We prescribe our medication.  And you know, it's very usual that we will to work even when we are sick.  And we expect the same from the colleagues.  I don't know if it's that familiar for you, but for me, extremely familiar.  Another important thing that we are in the ICU on the front line.  In this moment, in China, there are doctors and nurses in the front line.  What impact do we have in our relationship, in our family?  What happened to our heart?  This is not focused in ICU. I think it will be very important to have some studies about what happens to this topic in the ICU staff and what things our family about our work.  This is a very old paper, but it's a classic paper that shows you marry a doctor. And there is 22 to 50 percent of incident of divorce, and even worse, in NRs, that are between  60 percent.  There are some kind of speciality, but it's not intensive care in this paper.  So, what are the couple stressors most important for us? To get home tired, often we get home tired, and to arrive irritable at home.  And what we want, or the couples want, to be more hours together, less work nights, and less work hours.  And sometimes, we work more than 12 hours, and we work on the night, because that's our discipline. So, it's important to think about our family and our health.  Think about our family and our couples, too.  That's a photo that's something I feel like this, in this balance.  And there are some people that always think that the balance is very thin between family and what we are doing, you know, what is our job.  There are a lot of recommendations or strategies to improve or to prevent. This is from the Mayo Clinic.  So, we try to understand the problem, and we try to do some action plans to improve this.  I will show, in the next 10 minutes, the Project OUCI, what we are doing in the last six years that we were born, and what we are trying to do, and what we are willing to do.  This is our project.  You know, we are endorsed by a lot of society. One is your society, so we are extremely thankful for this.  A lot of people believe in us, and we are doing some kind of research with the European American Society, also with the Living Group, also with the Spanish Society.  So, we are trying to do a lot of things and to improve in these items. You know, we are rethinking and redesigning the healthcare system towards the model that  we believe that is a people-centered model, and the patient and the family in the center of the model.  In the wheel, we have a lot of topics, like open-door policy in ICU, communication, well-being,  presence and participation of the family, the care of the health professionals, preventing  management of post-discharge, the infrastructure, humanizing the infrastructure, and end-of-life care. So, there are a lot of topics to explore and to improve.  It's a worldwide and multidisciplinary team. It started in Spain, but now it spreads over a lot of continents.  And the most important is a multidisciplinary team. There are nurses, patients, families, there are psychologists, architects, physiotherapists, and others.  So, it's very important to be multidisciplinary and to learn from each other.  This is Cathy, that you saw the video.  What are the research areas? One focuses on the patient, another on the families, and another on the health staff. That's our main research areas.  We have this vision.  There are some people that believe that they don't want to join the project, and it's okay. They don't want to join the project, and it's okay.  But we believe that it's good to do this project and to explore what we are doing and the future of humanization intensive care.  We have 85 scientific publications that are very important to diagnose the situation and have action plans.  It's not important, the scientific publication, if we don't change the things.  The first was a plan from improving the humanization intensive care.  This is what we are speaking in the plenary, humanizing intensive care towards a human-centered care ICU model. That's what we believe to do.  We have the first book, and I hope it will not be the last.  It's in Spanish.  We also are very proud that we have a manual of good practice for the humanization of intensive care.  We have 160 good practice, and we are revisiting every day if they must change or not.  They are in Spanish and Portuguese, but we must translate to English in the next month.  These are the strategic lines that we have, focused on the three topics that I told.  We have a certification process in good practices, external certification process in good  practice, that for us is very important because it's a part of the quality that we are doing  in the ICU.  Safety, humanization, it's all the same. It's quality.  We have the first unit certified. It was in December last year, so we are very proud that we have the first.  And this year, we hope we have more units certified in the process or the culture of humanization in the ICU.  We have a master in the Universidad of Barcelona, University of Barcelona, and I think it's very important to teach another items, like I told, not only technical skills.  So we have a master that is going in the second year.  And beyond the ICU, this dream that we started three years ago, now they are in the emergency. Humanization in oncology, in radiology, and even in management.  So there are some work people in another disciplines that they are with their own projects. And we are very proud that they, there are more and more specialties that they have their  own projects. And beyond the hospital, now there is a project in the police people, it's called H-Police  Project, and there is a project that is leader by lawyers in the justice, that is called humanizing the justice.  So these are another examples that the people start to do it in another disciplines, in another professions.  So I will show in the next three minutes our last congress that was in Valencia. You are invited to our congress that in this year in Madrid, and we have a very special  our congress that in this year in Madrid, and welcome to our blessed madness, that is one of our quotes.  The administrative part is done by the teachers.  We don't have staff.  These are workshops, communication, an expert in communication, music therapy, yoga, resilience,  resilience also.  This is a family member, a mother.  A patient, another patient, another patient.  Our communications, we have a part of communications, and this is Gabriel Heras, our leader.  So that's what it's about, to find people who make you see the things that you don't see, to look with different eyes. Thank you very much.

Video Summary

In this video, Dr. Nicholas Ninn discusses the importance of humanizing intensive care units (ICUs). He begins by highlighting the historical significance of humanization in patient care and the need to focus not just on technical skills, but also on communication, emotional, and spiritual skills. Dr. Ninn emphasizes the importance of good communication in the ICU, as it can have a positive or negative impact on patients and their families. He discusses the need for healthcare professionals to ask patients and their families what matters to them, in order to shift the focus of communication and care to their specific needs and preferences. Dr. Ninn also talks about the negative consequences of dehumanization in the ICU, including patient dissatisfaction, psychological distress, and nightmares. He discusses the impact of noise, light, and sleep disruption on patients' well-being, as well as the importance of involving families and children in the ICU care process. Dr. Ninn also highlights the impact of burnout and stress on healthcare professionals and the need for self-care strategies. He introduces the Project OUCI, a worldwide initiative focused on humanizing ICUs, and discusses various research areas and initiatives within the project. Dr. Ninn concludes by highlighting the importance of ongoing efforts to humanize ICUs and improve patient and healthcare professional well-being.

Asset Subtitle

Patient and Family Support, Quality and Patient Safety, 2020

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2020 Critical Care Congress held February 16-19, 2020, in Orlando, Florida, USA.

Humanizing Intensive Care

Nicolás Nin

Learning Objectives:

Describe the HUCI Project as a catalyst for cultural change in the Intensive Care Unit
Identify the best practices related to humanization
Evaluate the impact of humanization on results for patients, families, professionals, and organizations

Meta Tag

Content Type Presentation

Knowledge Area Patient and Family Support

Knowledge Area Quality and Patient Safety

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Membership Level Professional

Membership Level Associate

Tag Communication

Tag Ethics and End of Life

Year 2020

Keywords

humanizing intensive care units

importance of communication in the ICU

patient-centered care

dehumanization in the ICU

impact of noise, light, and sleep disruption

involving families and children in ICU care

burnout and stress in healthcare professionals

Project OUCI

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