Thank you so much, Alex. We had a conversation earlier this morning, and we had one months ago about the order of our presentations, and made a decision that perhaps I should go last because of my content. And I'm thinking a little more about it and thinking maybe I should have gone first because I'm going to show you and make an argument for team decision-making, especially in end-of-life decisions in the intensive care unit. And the take-home message is if the team can't get together about what the options are, then how are they going to be able to engage in true shared decision-making with patients or their families or their surrogates. So I'm Mary Faith Marshall. I'm at the University of Virginia, and I am the director of the Center for Health Humanities and Ethics there. No conflicts of interest. And my objectives are I'm going to show you how we developed a policy at the University of Virginia that focuses, sorry about that misspelling, on the health care team and policy development, the benefits of an effective health care team, and I'm going to discuss moral hazard mattering and moral community in relation to health care team effectiveness. So here's kind of a basic definition of what a health care team is or a description of it, that a health care team is a cohesive group with a shared identity, clarity, interdependence, integration, and shared responsibility. And I've highlighted shared responsibility there because it's important. I'm going to expand on that in a little bit. So here's a paper that came out in Critical Care Medicine in 2018 by Donovan et al. And you all probably know this, but we've got data. We've actually got robust data that tells us that effective teams, teams that work well with shared responsibility, have better patient outcomes than otherwise. And I'm pointing out here by an interprofessional team. And I'm maybe going to make an observation, and I know you don't practice this way, that there was a lot of conversation about physicians in the last two presentations and not about the health care team. And I know that's not how you practice, but I just wanted to point that out. Right, and so that you get way better outcomes. And the data also show us that members of the health care team are happier in their work when they function effectively, they have better outcomes, and patients and their families are happier as well. So more data, this is a paper that came out in 2014 in the Journal of Critical Care. And again, kind of reiterating the same thing. This was a systematic review. Evidence from across clinical domains shows us an association between quality of teamwork and a broad variety of patients harmed, as well as positive effects of team improvement strategies on perceptions of and objectively observed teamwork. And so this is data that you probably already know, and it makes sense. Okay, this is an interesting paper. This is an editorial that was published in 2016 in the American Journal of Critical Care. And they were, I think, making an observation and lamenting the fact that we don't always work effectively as teams in the intensive care unit. And so having made that observation, they say so that rather than suggesting that the work that we do in the intensive care unit is somehow not teamwork, perhaps we should refrain the issue. And in their view, the fundamental question is not whether the ICU team exists, but whether it's functioning well. And they identified three areas for improvement that I think are central to the effectiveness of teams. One is hierarchy. Other is input to decision making. And then the third is communication. And those of you who may do clinical ethics consultation, like Alex and myself and probably others in this room, know that communication and power differentials are often background conditions when we get requests for ethics consultation. This is a picture of the James River. I live in Richmond, Virginia. And kayakers who didn't do risk assessment very well, and there were several who were killed when they were kayaking over the James River after a heavy rain. So I show you this slide to talk about moral hazard, which is basically about risk assessment. And the idea came from the economics literature that moral hazard happens when one person or group is empowered to make decisions about risk and another group bears the burden of those decisions, the benefits or the burdens. Our former colleague, Don Brunquell, who's a well-known pediatric bioethicist who died this year on New Year's Eve, was the first, he and his colleague Phil Michelson, who is a health economist, to take the idea of moral hazard from the economics literature into the clinical world in their American Journal of Bioethics paper Moral Hazard in Pediatrics. And so they talked about it in the context of non-shared decision-making, right? So risk assessment and the power differential of those not involved in risk assessment or decision-making not being the ones to bear the outcomes of those decisions. One other thing that I learned from Don Brunquell, who's a fabulous Renaissance man sort of person, was that this reflects back on what you all were saying this morning about shared decision-making, and that is give parents a story that they can live with. Okay. This is from a paper that my colleague Beth Epstein and I wrote, and we just made the argument, building on the work of Brunquell and Michelson, that one, we made the observation it's not just in pediatrics, but this is really important in critical care across the board, and that assessment of risk appetite, careful consideration of disparities in risk, right, moral hazard, are fundamental to patient-centered, team-oriented care. I want to talk to you about the field of matter and research there. One of my colleagues, who is actually a pediatric intensivist, but she's on the faculty in the School of Nursing at the University of Virginia, has done a fair amount of work in mattering. And so mattering, you know, the work has been around for decades, right, the perception that you make a difference, right, in others' lives and that what you do is significant, right? It's different from meaningful work, right? And so if we think about some ways of expressing what does that mean, I feel that I matter to my colleagues and my coworkers, right, anti-mattering, right? Are you treated in a way that made you feel insignificant? And to what extent were you made to feel like you were invisible? So Julie Haislip is the pediatric intensivist I was talking about, and she has, you can see the correlation there between mattering and burnout, it makes sense. My colleague Beth Epstein and I, Beth has done a lot of the seminal research in the field of moral distress, have done a study that we've called The Last Straw, and we interviewed nurses and physicians around the country who not only were thinking about leaving their positions because of moral distress, but had actually left them. Those data will be coming out relatively soon. And here are a couple of papers that have to do with mattering and the relationship between moral distress, mattering, and secondary traumatic stress and provider burnout. Okay, so we can make the argument that we are all in the healthcare world and our academic health centers or our community hospitals or whatever sort of organization you practice in, that we are part of a moral community. And what do I mean by that? That our common moral purpose, moral purpose, transcends our personal interests and promotes the well-being of others, and that in the healthcare world, that moral community exists as well, and we should acknowledge it and we should use it as a fulcrum to make change, right? So, healthcare organizations' common moral purpose is to provide high-quality, safe care for patients, despite our very different roles. This is an excerpt from a paper by my wonderful colleague, Joan Liashchenko and Elizabeth Peter. They often write together, Fostering Nurses' Moral Agency and Moral Identity, the Importance of Moral Community, published in the Hastings Center Report. And the excerpt is that you would say to a colleague, I'm holding you morally accountable to take my concerns seriously because my part in the care of this patient is just as important as your part. Okay, so I want to show you how we put this into play. At the University of Virginia, when we developed our revised, what used to be a Do Not Resuscitate policy and is now our Code Status Orders and Associated Treatment Plans policy. And this may sound a little antithetical to you, right? The goal of the new policy is to create a process that's supported by an institutional system that enables effective conversation about the goals of care among and between members of the multi-professional health care team and with patients and their families planning for the future. And so here's a nut of it, like right here. The primary focus, henceforth, is on shared decision-making within the health care team. Right, and if you think about if you flew out here, right, on a plane and, you know, the oxygen for some reason has to be released from, you know, in front of you, right, that you put it on yourself so that you can then help others if you need to, right? Kind of same thing here. If the health care team can't come together on what should be offered to the patient or the family and how to engage in shared decision-making, then you're kind of lost before you start. When I came back to the University of Virginia in 2012, the do not resuscitate policy had this language in it. The University of Virginia Medical Center acknowledges that capable adult patients or authorized surrogate decision-makers have the right to decide whether cardiopulmonary resuscitation will be used in the event of the patient's cardiac or pulmonary arrest, period. No shared decision-making there, right? I was shocked, actually. So narrow focus, so what's the problem here, right? A narrow focus on resuscitation only does not address patients' goals of care or mutually agreed-upon goals of care, realistic goals of care, and there's a lack of shared decision-making. The health care team is left entirely out of the picture. And the way that policy was written, right, and the way that it was enacted, right, was just a setup for suboptimal communication, right? As has been said, right, earlier this morning, it frames the decision around code status, right, rather than realistic goals of care. Often what we find is that when you narrow it down that way, it stops conversation. I think you all both mentioned this, right, and so that there's inadequate family and patient speaking time to have a real conversation. We dance around uncertainty instead of being forthright, as Wynn pointed out, and we often use euphemisms instead of language that makes sense to patients and their families and their surrogates. So we started in 2015, and I knew that this paper was coming out from the Society of Critical Care Medicine, and so I waited at our institution until the paper was published so that we could use it as a national standard. And so it took us two and a half years to enact our new policy, and we went through a robust process. You can see the multiple stakeholders there throughout the institution, and that worked really well for us, 30 people on our medical center working group, and it was an iterative process back and forth to a number of stakeholders you've already seen, as well as the leadership in the institution. Every draft of the policy went that direction, and these were the review groups that were part of that iterative process. And so this is what the policy looks like now. This is the introduction to the policy, and you'll see it says, Code Status Orders and Associated Treatment Plans. We have three levels of DNAR, Do Not Attempt Resuscitation, and the A is there for a reason because, as was pointed out earlier, most of the time, right, 75% of the time when a patient has an in-hospital arrest, it's not successful in terms of survival to discharge. So don't attempt. If you say don't, do not resuscitate, the implication is that it works, when most of the time it doesn't. And so three levels of treatment plans, DNAR A, Do Everything Except Attempt Resuscitation, DNAR B, it's a time limit of trial of the current treatment plan, and C is comfort care only. But this is what I want to point out to you. So this is the new policy. UVA respects the rights of patients or legal surrogate decision-makers to be informed about and involved in decision-making regarding all aspects of the patient care, including the right to consent to or refuse offered resuscitative interventions or other life-sustaining treatments. The medical center respects the rights of healthcare team members to maintain their professional ethical integrity. The team is not required to and should not offer or provide interventions that are outside the boundaries of clinical practice. And then just one last thing here to point out. So we define team in our policy, and the healthcare team, basically the people who are going to be attempting that resuscitation at the bedside and who provide direct care at the bedside. So it includes the attending physician, the LIPs, the nurses, the respiratory therapists involved in the patient's care, and we define what LIP is. And so you'll see here that when discussions are held about whether to forego resuscitative interventions as part of the patient's goal-directed plan of care, the healthcare team documents in the note. And so it may be the attending physician or the resident or the advanced practice nurse or other person who writes that order, but the order set requires that you document who among the healthcare team was involved in that arriving at that decision and LIP healthcare team considerations. So focus on realistic goals of care, not just code status. Explore patient family values, perceptions of illness and hopes. Explore how the patient and the family prioritize these goals. And you've seen some of these papers already, but they're for your edification if you need them. And so that we can hope that by involving the team in what to offer and respecting and institutionally upholding their professional norms and values and integrity, healthcare workers in the ICU may look less like that and more like this. Thank you, everyone. Thank you.

team decision-making

end-of-life care

code status orders

patient-centered care

healthcare team cohesion