Hi, welcome to our session today on ICU burnout, moral communities, and resolving conflict. I'm pleased to say that we've put together a great panel of experts from across the country. We're going to look at a number of different ways that we can work on burnout and conflict, and especially with an emphasis now on COVID-19 and how that's affecting ICUs across the country and across the world. So with that, I'm going to move on to our first speaker. Thanks very much for joining us. Hi, my name is Beth Epstein. I'm from the University of Virginia. I'd like to introduce our study team, Mary-Faith Marshall, Julie Haislip, Rachel Bennett, Helen Schmeche, and I'd also like to acknowledge that this work comes from funding from the AACN Impact Award. Today I'm going to be talking about a study that we conducted called The Last Straw, where we sought to identify upstream triggers of burnout for physicians and nurses. I'd acknowledge that I have nothing to disclose. The purpose of this study was to study the upstream triggers of burnout, specifically moral distress events and mattering. Moral distress occurs when clinicians know the right ethical action to take but cannot take it. A critical care example would be a patient with a very poor prognosis whose surrogate decision maker demands continued aggressive treatments despite there being little to no benefit to those treatments. The patient is in pain and suffering and the harms outweigh the benefits. Moral distress has been identified as a predictor of burnout in previous quantitative studies. Mattering is defined as the perception that one makes a difference in the lives of others and is somehow significant in the world. It's common for healthcare providers and others to want work that's meaningful. The concept of mattering flips that perspective a bit to examine how we are meaningful to others. A recent study of nurses, physicians, and social workers and therapists by Julie Haislip and colleagues identified a negative correlation between mattering and burnout. This suggests that when healthcare providers feel they matter to others at work, they are less likely to feel burnout and vice versa. We conducted a two-part study including an online Qualtrics survey and in-depth semi-structured interviews. Patients were recruited through Facebook and Twitter and were eligible if they had left or were in the process of leaving their position due to burnout. The survey consisted of demographic and work-related questions as well as a reason for leaving. We also included a five-item anti-mattering scale which internal reliability was good as evidenced by a Cronbach Alpha of 0.92. Higher scores indicate lower perceptions of mattering. An example question is how often were you treated in a way that made you feel like you were insignificant? Interviews were done by phone and were audiotaped for accuracy. In all, 237 people responded to the survey and of those, 128 were complete. Most were nurses and there was a wide range of clinical experience ranging from 1 to 45 years. We asked about their reason for leaving. About half indicated that they left due to burnout specifically or dissatisfaction such as staffing stressors or they didn't like their manager or that kind of thing and half left for reasons unrelated to burnout such as moving or gaining education that led to a different position, a change in position. There were no significant differences in years in position between the burnout, the not burnout like moved or educated education group and the dissatisfaction group. However, when we evaluated, analyzed differences between mattering, anti-mattering, we found that higher scores, the burnout group had much higher scores or significantly higher scores than the non-burnout group. There was no difference between the burnout group and dissatisfaction group or between dissatisfaction and the not burnout group. This suggests that in congruence with Julie Haislip's study, higher levels of anti-mattering, meaning that you feel you do not matter at work, correlated with higher levels of burnout. Next, we have conducted 24 interviews. 20 of those have been analyzed. In all, 22 of these were nurses and 2 were physicians. We're still analyzing the qualitative data, but we are seeing some themes emerge in the areas of burnout story, last straw event, mattering, and moral distress. These are the issues that I'll speak to. Our first question was about their burnout story. One of the most common themes we heard that emerged was that of poor organizational leadership as evidenced by these quotes from participants. One emergency department nurse said that she had 13 patients and she was in charge and she had a float ICU nurse. Then the other nurse that she had on staff had only been a nurse for 10 months. The unit was chaotic and busy and she had far too much to do and the leadership had no interest in listening to how dangerous that situation was. An ICU nurse noted that organizational leadership was deaf to her concerns when she raised them, even to the highest levels. She recalled telling an attending and an HR representative that you can't have a resident doing surgery on a patient without an attending president. It doesn't matter how much you trust them or how good they are, it's fraud. She was ignored fully when she conveyed that to the HR department. There's a resounding message of a lack of interest in hearing clinician input at the institutional level and so just the continued deafness was a real problem. There's also, we heard a fair amount about unit management and unit management problems where this is from an ICU nurse also who said that she had, her burnout story included a patient who went home very hypertensive. She had brought this to the attention of the attending physician. The patient got home and had an event and she was brought into the manager's office and was told there would be an investigation against her because she had sent a hypertensive patient home and she described how that was really not fair. So this organizational problems were very common in last, in burnout stories. We also heard concern about poor patient care from about half of our population, participant population. Many felt very unempowered to take action and a couple of examples are here. One was that a nurse was told that she was supposed to go in and get informed consent for a complex surgical procedure that was going to be happening the next day. She was new on this unit and she was told that it's the nurses that discuss the procedure and fill out the consent form with the patient. When she raised concern, her manager told her that the surgeon will insist on the patient signing it anyway because they don't want the procedure to be delayed and she was very concerned about that. That was very poor patient care. There was also a concern from the physicians in the group or a physician in the group that patient care was delayed until the patient was more stable rather than sending the patient to another hospital where they could be cared for more appropriately. She was very concerned that this was very inappropriate over time. We also asked about what the last straw was. What was the last straw that made you realize that you needed to leave your position? Several participants noted that it was just a series of small things that built up over time. It was a variety of different things like chronic hostility, chronic lack of support, chronic understaffing, acceptance of poor patient care. It was all kind of encompassed in the environment and the culture. There was also concern from many of our participants about continued bullying and chastising that just was relentless and just didn't end. Those were the last straw events. We didn't ask about, but we looked for evidence of moral distress in their burnout stories and the stories that they were conveying about why they felt they needed to leave their position. We could categorize these in three different levels. One was poor patient care. This was at the patient level. They felt unempowered to do the right thing for patients. One was at the unit level where there was poor teamwork, poor collaboration, poor communication, a lack of interest in hearing about disagreement or concern from other perspectives. And then at the institutional level, chronic understaffing was a real problem. One participant noted that it was the suck-it-up buttercup attitude of leadership and weak support from ethics consult service, no place to go for help, that were really problematic. We also looked for situations in which clinicians felt like they did not matter as kind of upstream triggers of moral distress, of burnout, sorry. We found that this actually was one of the most prominent issues that kind of hit us over and over and over throughout the participants' stories. We heard repeated stories that they felt they mattered much to their patients and their patients' families. Often, they mattered to their coworkers, but to their institution, they were just another number. They were expendable. They were easily replaceable. They were told to shut up and do your job. Many told us that they felt there was no difference whether they stayed or left, and they conveyed the fact that the institution needed workers, not me personally. And they felt that when they raised concerns, their concerns were ignored or they were patted on the hand and they were just being placated, so they were not being taken seriously. And this really was a very prominent trigger repeatedly in our stories. So we still have yet to analyze several parts of our data. We asked about what regrets they might have or what made them particularly proud with regard to their burnout situation, what kinds of resources would have helped them or would have made the organization a better culture or environment. We have yet to triangulate data related to what we were seeing were ICU stories were a little bit different than acute care and outpatient stories. And we also saw that some clinicians conveyed to us that they were night shift employees and that might shape their burnout stories as well. So we have yet to triangulate those data. I wanted to mention one important thing that we did not see in any of our participant stories, and that is that we did not see EMR and excessive documentation issues as sources of burnout in this study. Those may have been embedded in the whole environment and cultural issues, and many participants discussed the environment and the culture that they worked in being the source of their burnout, but none mentioned excessive documentation or EMR issues. And I know that this is an important factor and has been shown in some quantitative studies of linking EMR and excessive documentation to burnout and also to moral distress, but we did not see that in our qualitative interviews, which I think is interesting and an area for additional study. Thank you. Good afternoon, everyone, and thank you so very much for joining our session. I'm Mary Fink-Marshall from the Center for Health Humanities and Ethics at the University of Virginia. I'm also a member of the Society's Ethics Committee and the Ethics CAG, and I'd like to take this opportunity to say please join the CAG if you're interested in ethical issues in critical care, and please let us know if you have any interest in joining the Ethics Committee. I'm going to build on what you've learned so far from our other excellent presenters, but I'm going to look at burnout not just from the bedside or the unit level, but from a 150,000-foot view that includes organizational and executive leadership in health centers. I have nothing to disclose. I'd like to acknowledge a wonderful group of colleagues and co-authors of the paper you see on the slide in front of you, Moral Distress, Mattering, and Secondary Traumatic Stress and Provider Burnout, a call for moral community that was published earlier this year in AAC and Advanced Critical Care and informed a number of the thoughts that I'm going to present to you today. So in their 2017 call to explore and address burnout among healthcare professionals, the members of the National Academy of Medicine Working Group and authors of a discussion paper considered the threat that burnout poses to the safety and quality of healthcare delivery. So there I applaud their serious attention to the well-being of nurses and physicians, especially their call for focused research on organization and system factors associated with burnout, depression, and suicidality. For those of you who haven't read the paper, they presented their list of concerns in the order that you see here, quality and safety, patient satisfaction, turnover and reduction of work effort, and healthcare costs. I ask you to think about this list and its implications for critical care providers because I think they relegated the most important thing to the end of the list. I would argue that not one of the foregoing concerns can be successfully addressed unless personal costs, including the emotional costs of care, are attended to and that they should be first. In 2016, a year before the National Academy's paper was released, a joint critical care society's collaborative paper on burnout syndrome in critical care health professionals was published. In both nurses and physicians, problems with the quality of working relationships were common risk factors for burnout syndrome, including not only workload, lack of control of the work environment, insufficient rewards, but a general breakdown in the work community and that word community is important. So I think the authors of this paper got it right in putting the onus on ICU leadership and hospital administrators to mitigate and rectify risk factors for burnout, but they got some really important things wrong too. For example, this statement, which exemplifies some of the structural problems that are at the root of burnout. In contrast to nurses, physicians may less frequently experience moral distress, most likely because physicians are responsible for making the patient care decisions. This is a retrograde idea. Imagine how you would feel if you were a critical care nurse reading this. Here's another prime example and I'll discuss this in more detail in a minute, but the idea here, the fault, is the notion that we as critical care providers should take individual accountability for maintaining our emotional and physical health and for building resiliency. So that we should be personally responsible for managing our own burnout symptoms and related consequences. There's an interesting paper that was published this year in the New England Journal that really gets, I think, at the root of the problem and that is that health care leaders are rarely held accountable for outcomes that relate to their employees' well-being. That is perceived by clinicians as eroding trust because administrators, leaders who are responsible also for the well-being of clinicians are not doing the work that needs to be done to prevent the mitigating and causative factors. So here's another important piece of research and that is, again, this paper from the New England Journal that says that it's workplace issues that should be mitigated and those of us, you know, as we know, we are smack in the midst of this awful pandemic which has really escalated the problems and the concerns of inadequate resources, unsustainable clinical volume and hours, and unprofessional and problematic behavior, which too often go unaddressed. There's an interesting survey by Tate Shanafelt and others who work at the Mayo Clinic. They surveyed physicians in their organization about burnout and its causative factors and the effects of leadership on those causative factors and they found out that variation in burnout was explained by how leaders are rated and that each one-point increase in a leadership score was associated with a 3% decrease in burnout likelihood, which shows you the importance of strong leadership. Talbot has made an interesting argument that the situation in many healthcare institutions goes beyond burnout, right, but that clinicians, physicians are suffering instead from moral injury. Moral injury first came about in research that was done on soldiers during war and it's only recently been applied in the healthcare setting. Moral injury occurs when there's been a betrayal of what the individual feels is morally right by someone in authority in a high-stakes situation and you can see the sequela of moral injury there and they look very much like the sequela of burnout. Weibel goes even further. Weibel describes burnout as victim blaming and shaming and that it is a term of oppression that covers up the abuse of clinicians by those who lead dysfunctional and highly toxic healthcare systems. She says that neither burnout nor moral injury is sufficient to encompass the harms that are done to physicians and we would say other clinicians and she reframes this abuse as a violation of human rights. The focus of my talk is moral community and how those of us who work in healthcare settings are members of moral communities and that we are responsible to and for the well-being of others, not just ourselves and that a healthcare facility in its whole is a moral community and it's based on the idea that each of us is a moral agent, that we understand the responsibilities of our role and our mutual responsibilities to one another relative to the values of our particular healthcare community. Joan Liashchenko and Elizabeth Peter wrote a wonderful paper in the Hastings Journal Report in 2016 and they said that moral spaces, which is an idea that was articulated by the philosopher and bioethicist Margaret Urban Walker, is that we need moral spaces that are open and that include not only patients, but health care providers, because each of us, all of us, require care. And in their paper, Peter and Leo Shinko make this argument that I, as a critical care nurse, or physician, or respiratory therapist, or other, would say, you are morally accountable to me and to take my concerns seriously, because my part in the care of this patient is just as important as your part, just thinking back to the slide about physicians making the health care decisions. And so moral communities are responsible to everyone in that community, including the folks from environmental services, from nutrition, and so forth. All of us are responsible to one another. Seana Felt, Tate Seana Felt, and John Noseworthy from the Mayo Clinic have made this really interesting argument that they put into place at the Mayo Clinic. And they say, you know, all of our health care organizations routinely assess things like patient volume, pay or mix, quality and safety, patient satisfaction, and financial performance, right? And we know that physician and other health care clinician well-being is just as important to the health and the long-term viability of the organization. And it needs to be measured, too. So how do we do this? So Seana Felt and Noseworthy, and I should say John Noseworthy is the president and CEO emeritus of the Mayo Clinic, have said we need to establish organizational performance targets, not just on the ones I spoke about a moment earlier, but how those targets are achieved by leadership as evaluated by the people they're leading. They've written a great paper, Physician and Nurse Well-Being, Seven Things Hospital Boards Should Know. And I commend this paper to you if you've never had a chance to read it. And so these are the seven things. We know burnout is prevalent among health care professionals, that the well-being of health care professionals directly affects quality of care, that distress, replacing critical care clinicians costs a lot of money, and it costs organizations money in other ways as well, that looking to the individual for resilience is not the solution. And you've heard me say that other authors argue that it is blaming and shaming, that different occupations and disciplines have unique needs, that we know how to address the problem, and those interventions work. So what they've done at the Mayo Clinic is that they have used metrics at the division and the department level that lets leaders identify what they call high-opportunity work units. And so those are units where prevalence of burnout, engagement, and satisfaction needs to be addressed because those scores should be higher than they are. And an important thing is that they categorize these units, the metrics are external benchmarks, not internal benchmarks, so that no units or perhaps all units could meet those benchmarks or fail to meet them. And the other important thing here is that these same tools are applicable to other health care professionals and other job types so that you can have a comprehensive assessment of the institution. So, again, the organizational strategy identifies high-opportunity units based on external benchmarks. So what they do now at the Mayo Clinic is that the physicians and actually other clinicians as well evaluate the leadership behaviors of their immediate supervisors using the scale for burnout and satisfaction, and you can see that the URL is listed here in my slide, and that this information is used for annual performance reviews with executive management. So John Noseworthy, who, again, is the president and the CEO Emeritus of the Mayo Clinic, has these goals related to the parameters worked into his annual evaluation by the board of trustees. And so the argument that I'm making is that we should adhere to this sort of approach, and a number of other institutions, including Stanford, have done so, in order to make the organizational leadership at the highest level responsible for mitigating burnout and dissatisfaction of its employees. So the bottom line, we each think about our roles, and within those roles, what are our responsibilities to ourselves, to our patients, and to one another, and thus, what are our mutual accountabilities? And in essence, we are all in this together all of the time. And all good wishes to you and to your colleagues, especially during this difficult time of the COVID-19 pandemic. Thank you. Thanks so much for having me. Today, I'll be presenting on the topic of making decisions in ICUs for unrepresented patients, ethical issues, and new recommendations. So let's start with a couple cases. The first case, and just to illustrate what we mean by an unrepresented patient, imagine an elderly woman is admitted to your ICU after a cardiac arrest. She's there for 10 days. She remains intubated and is minimally responsive. Neurology consultants are involved. They confirm hypoxic ischemic brain injury and say that she'll likely have profound neurologic impairments but could have some marginal gains in neurologic function over time. They anticipate that she'll likely need a feeding tube and ventilator if she's to continue to survive. So she's outlived all her family and friends. She lives alone. She has no primary medical doctor, and she has no advance directive. Her attending physician, when thinking about goals of care and what's appropriate and what's allowed, is unwilling to consider anything other than ongoing life support because she lacks a decision maker. All right, so that's the first case. Let's talk about the second case. This is a 45-year-old previously homeless man who's admitted with septic shock. And for the last two years, he's been a resident of a skilled nursing facility because of severe cognitive and functional impairments that have arisen from CNS complications of heroin abuse, specifically numerous embolic strokes. So he also lacks decision-making capacity. He has no friends or family available, also has no primary care physician, and has no advance directive. However, in this case, obviously, it's a different attending physician. He says this is a poor use of resources without providing much more context for that, and plans to write an order for comfort-focused care. So I think both of these cases, in aggregate, illustrate the potential concerns in making decisions for unrepresented patients, which is to say concerns for overtreatment and undertreatment without adequate procedural safeguards. Well, so let's start with the definition. What do we mean by an unrepresented patient? An unrepresented patient is someone who lacks, number one, decision-making capacity, number two, an available surrogate decision-maker, and number three, an applicable advance directive. So who are these patients? Well, they come from a variety of places in society, but these are often socially isolated individuals. For example, community-dwelling older adults who have outlived all their friends and family. We also see these patients from homeless populations, those individuals who are also socially isolated in that community. And then finally, persons with psychiatric illness who have become estranged from family and friends. What I think is really important to note about this patient population is that these are individuals who are often socially marginalized and stigmatized, which is to say they're a vulnerable population. Well, how common is it that we encounter unrepresented patients in the hospital setting, and in particular, in the setting of intensive care? David Ash and colleagues did a survey of almost 900 physicians, and they found that 33% had withdrawn mechanical ventilation in at least one unrepresented patient during their professional career. Unfortunately, this study did not provide any information about how the decision was made, who was involved, and what factors went into the decision-making process. But what I think is really important about it is that it suggests that this is not a rare event in the practice of intensive care medicine. So why are these cases ethically difficult? You know, I think one of the main reasons is that we spend so much time trying to respect patient autonomy in intensive care, particularly around goals of care decisions, but that principle is unequivocally unhelpful in these cases, because these patients, by definition, can't give an autonomous treatment preference, have never written one down, and don't have anyone to speak for them. As I said before, this population is vulnerable to both overtreatment and undertreatment, as evidenced by the two cases I presented. And again, they're socially marginalized, or often socially marginalized, with a history of discrimination, which raises concerns that decisions could be influenced by either implicit or explicit bias. And then finally, without family or a patient-appointed surrogate, it's really unclear who has the moral legitimacy to make treatment decisions for these patients. So just a little bit more data about the prevalence and nature of decision-making for these patients. In 2007, we studied over 3,000 consecutive ICU admissions at seven medical centers across the United States. And what we found was 6% of the deaths in ICUs during the study period were among unrepresented patients, and parenthetically, that range was across ICUs from zero to 24%. So quite a lot of variability within and across hospitals. And we also asked the physicians how they made the decisions, and who was involved, and what was the oversight process. And what we found is that in 81% of such cases, the physicians and ICU team made the life support decisions without formal hospital or court review. So let's talk about that. So should treating clinicians make these decisions independently? Well, I think there are certain advantages to clinicians doing so. They have a professional duty to act in the patient's best interest. They have arguably the best understanding of the medical facts, and it's an efficient decision-making process. And we'll come back to this issue of efficiency later. However, there are some very substantial cons to physicians and other clinicians making independent decisions without any oversight. First, this would be a major departure from the norms of medicine, which really entails physicians and patients or their surrogates making decisions in collaboration. And in fact, patients or their surrogates have the final authority to accept or reject offered medical interventions. Second, physicians undoubtedly have competing ethical obligations as specified in the Charter of Medical Professionalism. Physicians have obligations to other patients as well. And it's unclear how a physician should balance, for example, his obligations to the individual, unrepresentative, unrepresentative patient with his or her obligations to other patients. And then third, as I've mentioned, there is risk for individual bias in these decisions. As individuals, there's the risk that idiosyncratic beliefs may unduly influence the decisions. And Deb Cook has done a lot of work looking at variability in physicians' decisions around life support, and has found that when presented with the same case, physicians often come to very different treatment recommendations about what should happen regarding goals of care. And then finally, there's also evidence that physicians have systematically different beliefs, which is to say that they bring their own biases to the decision-making process compared to patients. There are also some procedural limitations or concerns if individual physicians made decisions on their own. First, there are questions about whether physicians should have or do have the needed legitimacy to make these decisions. Second, there are concerns about transparency, which is to say, how would we know the basis for these decisions? Can they be reviewed retrospectively? And then finally, if individual physicians are making these decisions without a broader institutional input, there's little opportunity for institutional learning over time, which is to say, learning how to better manage these cases over time. But the other option, or another option on the other extreme, is to have a guardian appointed for every single unrepresented patient in the ICUs. And the big picture problem with this is that it's given the current realities of the guardianship system, it's simply not realistic. There's dwindling funding for guardianship, public guardians. There are very pressing cases of ongoing elder abuse that often get priority rather than cases that are in the hospital. The response time consequently is very, very slow on the order of many weeks sometimes for cases, which just doesn't keep pace with what's happening in ICUs. And then there's concerns that the guardians either may not be adequately attuned to and educated about the issues of decision-making in the critical care setting, and there may simply be insufficient judicial oversight given the very large volume that these public guardians carry. So in this context, the American Thoracic Society and the American Geriatric Society released a policy statement on making medical decisions for unrepresented patients. And I want to acknowledge that the Society for Critical Care Medicine also endorsed these recommendations as did the Neurocritical Care Society. This was an interprofessional multidisciplinary expert committee that had expertise of critical care medicine, palliative medicine, pediatric medicine, nursing, social work, geriatrics, patient advocacy, philosophy, elder law, and health law. And the group laid out five ethical goals to safeguard decision-making for unrepresented patients. First, to protect these highly vulnerable patients. Second, to demonstrate respect for persons. Third, to provide appropriate medical care in a timely way, I should add. Fourth, to safeguard against unacceptable discrimination. And fifth, to avoid undue influence of competing obligations and conflicting interests. And the first recommendation, and actually the first two recommendations are really focused on prevention. So the first recommendation is that institutions should promote advanced care planning as a way to prevent patients at high risk for becoming unrepresented from meeting this definition. And basically what this means is helping adult patients identify a preferred surrogate decision maker if there might be one, and also to record their treatment preferences in advance. And obviously for this to be effective, it also needs to be, the documentation needs to be available to clinicians at the point of care. The second recommendation is also preventive in the sense that institutions should implement strategies to determine whether seemingly unrepresented patients are in fact unrepresented. And what this means is both carefully assessing patient's decision-making capacity to see if they may be able to make decisions on their own, and also if the patient lacks capacity to really diligently search for potential surrogates among the patient's family and friends. And this can be quite an extensive process. Social workers at hospitals are often very good at exploring all kinds of avenues to find individuals in the patient's community who know them and can at least speak to their values and life history. The third recommendation is about how to make decisions when there is an unrepresented patient in the ICU and goals of care decisions or other major medical decisions need to be made. And the recommendation is that institutions should manage decision-making for unrepresented patients using a collaborative approach between the clinical team and a diverse, interprofessional, multidisciplinary committee, such as the Hospital Ethics Committee. And what's really important about this is rather than ad hoc decision-making only by the treating clinicians, the recommendation is that there be a collaboration between the hospital committee and the clinical team in making decisions together with some oversight. The goal here is to strike an appropriate balance between excessive and insufficient procedural safeguards. The fourth recommendation is the criteria for decisions or what should influence what decisions are made for these unrepresented patients. And the recommendation is that institutions should use all available information about the patient's preferences and values to guide treatment decisions. If no such information is available, the committee should collaborate with the treatment team to make decisions in the patient's best interest. And the final recommendation is a procedural one. It's about fair processes. Institutions should manage decision-making using a fair process that comports with procedural due process considerations, such as transparency, legitimacy, and consistency. And what this means is that there should be careful record-keeping about who is involved in making decisions, what decisions were made, and what the bases for the decisions are. And there should be efforts within institutions to strive for consistency, which is to say that similarly situated patients, ethically similar, should be treated in the same way. So I'll conclude here. And the conclusion is that the American Thoracic Society and the American Geriatric Society recommend that institutions should manage decision-making for unrepresented patients using collaboration between the clinical team and a diverse interprofessional hospital committee rather than ad hoc by treating clinicians. Thanks very much. Hi, I'm Alex Kahn. I'm a pediatric intensivist at Community Medical Center. And I'm going to be talking a little bit about key factors of avoiding conflict and resolving disagreements in the ICU. I'm a pediatric intensivist, so my examples are going to be in pediatrics, but I do ethics consultations on the adult side as well. And so everything that I'm going to be saying is really applicable to the neonatal, pediatric, and adult ICUs broadly. I have no financial conflicts of interest to disclose. I'm going to be talking predominantly about two types of conflict in ICUs. Firstly, I'm going to be talking about conflicts between doctors and nurses with other ICU staff members. And then we're going to move on to talking about conflicts between ICU teams and families and surrogate decision makers. So first, let's talk a little bit about conflicts between predominantly doctors and nurses. And we see a lot of these kinds of conflicts in all sorts of ICUs. So some examples of conflicts that we see not infrequently, sometimes doctors want to continue aggressive treatment, but nurses feel that comfort care is more appropriate. Alternatively, sometimes we see doctors moving towards comfort care, but nurses feeling that lifelong treatment is more appropriate. There's lots of other kinds of conflicts, but these are some of the ones that we see most commonly. So here's an example from my practice. Three-year-old child who unfortunately drowned. 45 minutes of resuscitation before return of spontaneous circulation. We're now six days post-drowning, and unfortunately this child has no purposeful movements, which is horrible prognostic indicator. Doctors and the doctor and the parents have lots of conversations and eventually come to a decision jointly to stop medically provided nutrition and hydration because they feel that the child simply is no longer benefiting from those interventions. The nursing staff becomes very uncomfortable. Folks start hearing terms like, we're starving this child. And there's a lot of discomfort among the nursing staff as well as RTs and other ICU team members. And this is kind of a common theme that we've already been hearing about where doctors are perceived to have the power and nurses lack the authority to overrule doctors, which leads to moral distress, as we've heard from several other presentations already in this group. So how do we avoid conflict? Well, one of the things that we can think about doing is having open discussions among the team before presenting options to family members. And this becomes very helpful because that way team members can talk about these options before families start hearing about them. We can lay out what do we think are the ethically permissible options and which are not. And if there are questions, we can actually get a healthcare ethics consultant involved early on so that everyone's on the same page before we start talking to families about what their options are. Giving all team members the space to talk, make suggestions and raise concerns is really important. Including staff and discussions with family can be very helpful so that staff and doctors are all in there together talking with families and hearing what the family's thinking and where they're coming from. And finally, including staff in the actual decision-making team, if the family is interested in willing to do that, can be extremely helpful. But there are, of course, several barriers to doing that. For example, at times decisions need to be made very quickly, which makes it very difficult to bring the entire team together. In units that lack primary nurse staffing, changing staff may make it difficult to include staff in discussions. Staff may not be supported or willing to come in on non-work days to participate in those discussions. And when they are working and taking care of patients, they may be too busy to leave the bedside and come and discuss these issues with the family. Doctors may be uncomfortable including staff in discussions. And sometimes families don't wanna have staff participate in the decision-making team. So how do we break down those barriers? Well, we develop a culture in the ICU where doctors and staff work together collaboratively in decision-making. So really creating that culture in the unit is very helpful and important. We need institutional support for staff participating in discussions, whether that be paying staff when they come in on their days off or allowing for enough nursing staff so that if the bedside nurse wants to come and be part of that discussion, another nurse can take over the care of those patients. We need education and training for doctors and staff regarding team-based decision making and collaboration, and we need support services to facilitate education and discussions, which oftentimes requires bringing people in from the outside to help do that education and training. So how did this case get resolved? So we ended up having four large meetings open to all ICU personnel. There were four meetings because we had two day shift teams and two night shift teams, and that way everyone was able to participate in some of those discussions. We had a neutral facilitator who can facilitate without taking sides, and there was an open discussion. So the doctor educated the staff about the prognosis and the family wishes. There was space for staff to voice their concerns, and the doctor practiced active listening. We actually worked with the doctor before the meeting and did some role playing to help that doctor get ready for this meeting. And we had a team-based discussion about how to best support the family and staff. And in the end, although there were still a lot of staff that were uncomfortable with the care that we were giving to this patient, staff understood why we were doing it, and we allowed for shifting of who was taking which assignments. And in the end, we felt that the ICU team felt that they were giving excellent care to this child and to this family, and people ended up feeling good about what they did, and that was really key. So now we're going to shift to looking at conflicts between the ICU team and the family or surrogate decision makers. Some of the things that we see the most, both on the adult and pediatric side, sometimes the ICU team believes that life-prolonging interventions are not appropriate, but the family wants to, quote, do everything. Sometimes the family wants comfort care, but the ICU team believes that aggressive treatment is appropriate. And I've seen a lot of cases where the ICU team questions the family motives. For example, keeping a patient alive may mean that they get ongoing retirement benefits or social security benefits that they might lose when that loved one passes away. Or alternatively, sometimes folks feel that family members would benefit financially through inheritance if a loved one passed away. And these types of concerns can lead ICU teams to question the family motives. So here's, again, another example from my experience. We had an 11-year-old boy who had actually drowned five years previous. He had an exam consistent with death by neurological criteria, but there was a court order forbidding formal apnea testing. The ICU team experienced a lot of moral distress in providing, quote, aggressive treatment to what they perceived as a dead child. ICU team members believed that the family was unrealistic in hoping for a miracle. And this was causing a lot of distress in the ICU. So again, how do we avoid conflict? So I would encourage everyone to take a look at the SCCM palliative-centered care guidelines. The new guidelines came out in 2017, updated from the former ones, and they're excellent guidelines. One of the things that we talk about is having regularly scheduled family meetings with a structured communication approach where we do active listening and express empathy. And it's been shown that doing these things can really improve communication and decrease conflict. Including a social worker can be extremely helpful for a number of reasons as well. Palliative care consultation, particularly early on in the ICU stay, can be extremely helpful. And ethics consultation with a trained and certified healthcare ethics consultant can be extremely helpful as well. So what are some of the barriers we see? Well, at times, again, decisions have to be made quickly, and that makes it difficult to bring the entire team together and do a really good job of communication and shared decision-making. It's difficult to make time and schedule family meetings. Doctors need to make time in their schedule, and nurses need to be able to get away from the bedside or come in when they're not on. Family members often have to take off time from work to come in. We're doing a lot of stuff by Zoom these days because of COVID-19, but that's also suboptimal because sometimes it can really be helpful to have everybody in the same room. So having a mix of virtual versus in-person meetings when COVID is over is going to be very important. A lot of facilities lack access to palliative care teams, which is really unfortunate. And a lot of places lack access to trained and certified healthcare ethics consultants, which can be a significant barrier. Teams may lack training in communication and collaborative decision-making. And finally, interpretive services may be suboptimal, which can be a big barrier. So how do we break down those barriers? Well, a lot of it really comes from institutional support and leadership understanding the importance of working on these issues. So communication training and collaborative decision-making training. Again, that oftentimes requires a lot of time and commitment from a lot of folks, sometimes bringing folks in from outside the organization to do that education and training. Access to high quality palliative care teams, that's critical, and that requires administration to really support palliative care. Access to trained certified healthcare ethics consultants, and this is key. There's still a lot of institutions that rely on volunteer ethics consultants. Oftentimes those people have no formal education or training in healthcare ethics consultation, and that can oftentimes lead to really suboptimal recommendations and facilitation, which is a big problem. So having access to either a full-time person at the facility or being able to consult someone from the outside, but having access to someone who's a fully trained, educated, and certified healthcare ethics consultant is very important and can really facilitate a lot of this work. And finally, access to high quality interpretive services is, of course, imperative. Without interpretive services, we really can't break down those barriers. So again, how did this case resolve? So in this case, we got an ethics consult with a trained certified healthcare ethics consultant who came in and did a lot of work. Developed a family meeting where we had members of the team and the parents there all in the same room at the same time, facilitated the process. And what it turned out was that family actually had very realistic expectations. They understood that their child would never improve, and they weren't hoping for a miracle because they knew that realistically this is how he was going to be. But the parents, like a lot of people in our country, don't believe that death by neurological criteria is actual death. They view their child as fully alive, and they felt that they had the same obligations to take care of their child that they had for all of their other children. They were very committed to being good parents and taking care of their child regardless of his neurological insult. And then we walked away from that team meeting and had more meetings with the big ICU team to really educate ICU staff about the family's rationale and minimizing moral distress. And that went a long way to really improving communication and allowing people to feel that they could give excellent care, understanding where the family was coming from, and it was very meaningful for a lot of our members. So a lot of places struggle with requests for potentially inappropriate interventions. And facilities should have a policy on how to deal with those intractable disagreements. At some facilities, the policy may say we do whatever the circuit decision makers want, and that's okay. Other places are going to have policies with a fair dispute resolution process that they follow in order to deal with these kinds of issues. And when they do that, they should really follow some national standards, ensuring non-discrimination and minimizing implicit bias, because those are very important. So SCCM signed on to a five-organization statement that supports the seven-step process, enlisting expert consultation, like a trained certified healthcare ethics consultant, to try to facilitate negotiations, give notice of the process to the surrogates, obtain a second medical opinion, obtain review by an interdisciplinary hospital committee. At many hospitals, that's the ethics committee, but some hospitals use a separate ad hoc committee for these issues when they arise. Offer the surrogates the opportunity to transfer the patient someplace else, inform the surrogates of the opportunity to pursue a legal appeal, and then finally, after all of that, implement the decision of the dispute resolution process. At times, there are time-pressured decisions that need to be made when there isn't enough time to go through all seven steps. And when that occurs, SCCM suggests that you obtain as much procedural oversight as the clinical situation allows, and if one of the following two situations are present, that you could potentially remove life-prolonging interventions, even over family objection, without going through the full seven-step process. And those two things are, one, if there's no reasonable expectation that the patient will improve sufficiently to survive outside the acute care setting, or two, if there's no reasonable expectation that the patient's neurologic function will improve sufficiently to allow the patient to perceive the benefits of treatment. If either of those things exist, then SCCM says it would be okay to go ahead and withdraw life-prolonging interventions over the family objection without the full seven steps if there isn't sufficient time. But if neither of those conditions are met, SCCM would say you really need to go through the full seven-step process. There's more information available, and I encourage everyone to take a look. So the Five Organization Policy Statement on Responding to Requests for Potentially Inappropriate Treatments in the Intensive Care Units, and that came out in 2015. SCCM put out a follow-up policy statement on defining futile and potentially inappropriate interventions, and that came out in 2016. I encourage everyone to take a look at it. And of course, the ATS-SCCM Statement on Shared Decision-Making in ICUs that came out in 2016. All of those resources are listed there on that slide, and I encourage folks to take a look and get more information. Thank you very much. Have a good day. Hi, I'm Ruth Kleinpel, and I'm delighted to be joining this session as part of the Society of Critical Care Medicine's 50th Anniversary Congress, which this year is virtual. And I appreciate the opportunity to present in this session that is addressing key factors in ICU burnout. We certainly can attest to the ongoing challenges that the pandemic has presented to ICU units globally, and certainly looking at ways to mitigate burnout has become of increasing importance for critical care clinicians. So I'll be presenting today on some results of ongoing surveys that the Society of Critical Care Medicine has been conducted relating to looking at the impact of the ongoing pandemic. So I have no disclosures, but I do want to recognize the efforts of Sarah Gast at Vanderbilt University School of Nursing, as well as Wendy Kollross, who is a Doctor of Nursing Practice student, for their ongoing assistance with some of the review of qualitative data from the ongoing surveys. So we all can highlight certainly that burnout continues to be an important quality of care metric for health care clinicians, and this is especially pertinent to those working in intensive care unit setting, especially during the ongoing pandemic. So looking at ways to address burnout becomes essential, especially as the pandemic is continuing to tax ICU resources as well as clinicians. A recent perspective in the New England Journal of Medicine highlighted the importance of supporting clinicians during the ongoing pandemic, and they highlighted that clinicians are facing important emotional stressors during the pandemic, including grief from seeing so many patients die, as well as fears of contracting the virus and infecting themselves. So certainly, this has been a challenging time this year for ICU clinicians. In their article, they highlight several ways that they are advocating for measures to help clinicians, including programs and resources that are developed at the organizational level, having peer support as an ongoing strategy for managing stress, reaching out to clinicians proactively, looking in at making sure that clinicians feel that they can reach in at any time to seek support, and most importantly, leadership support for addressing the clinicians' well-being within their organization. So definitely priority areas of focus. As part of the Society of Critical Care Medicine's ongoing efforts to monitor the impact of the pandemic, we formed a COVID-19 Rapid Cycle Survey workgroup, and so I do want to acknowledge those SCCM members who are serving on this workgroup, and that includes David Ferraro, Ryan Mays, Sandra Cain-Gill, Rich Branson, Steve Greenberg, and Luke Kaplan and myself, along with data support from Vanderbilt University, Dr. Ramila Raman and Jennifer Dorsum. So SCCM launched a series of Rapid Cycle Surveys, the first in March, the second in April of this year, the third in July, and the fourth most recently in December, each looking at the impact of the pandemic. And so out of those data responses, what I'm focusing in on today are the results of ongoing qualitative review of open-ended comments that were received from clinicians. So we received over 800 responses to open-ended comments that simply asked other response that clinicians could provide to the various questions, and we utilized a qualitative analysis using thematic analysis as described by Braun and Clark. And this is a six-step method that really requires one to review comments that are provided in-depthly, categorize them based on the comments that are being made, and then develop themes and really look at highlighting those themes in a formal way to look at predominant themes as well as sub-themes that are emerging and to really identify are there differences based on clinicians or based on their experiences. So this work remains ongoing, but today I'll be reporting on a subset of those responses. In terms of the surveys themselves, it was conducted through the Society of Critical Care Medicine in collaboration with the Critical Care Societies Collaborative, and that includes the American Thoracic Society, the American College of Chest Physicians, the American Association of Critical Care Nurses and SCCM, and also the American Association of Respiratory Care. So we had representation from all the providers, frontline providers in the ICU setting as shown here, nurses, physicians, pharmacists, respiratory therapists, as well as others that were working in the ICU themselves, and predominant number of responses came from nurses, and this really was due to the fact that the American Association of Critical Care Nurses was very generous in promoting the surveys to their members. They have over 150,000 members with their organization, so we're most appreciative of nurses providing information to us. With respect to the clinicians, majority had reported caring for a suspected or confirmed COVID-19 patient, and so certainly this gives us rich information about their ongoing experiences. So some of the results from the overview of the thematic analysis that really kept coming out, regardless of clinician type, was not enough ICU staff, not enough properly trained staff, the need to have clinicians who were not ICU clinicians learn to work in ICU settings, and certainly that is a challenge along with taking care of patients in the ICU. Certainly emotional and physical exhaustion came through on the themes, and then communication challenges with family members due to alterations in visitation practices. So sharing a couple comments with you, here's one. As a provider in an ICU setting, we are not entering the room as often as we would if they were not in strict isolation, so I feel like the patients are not getting the care they normally would. Another highlighted, patients are dying without their families. We are FaceTiming with family members during the death process, but this does not support families enough. Another highlighted, imagine the patient anxiety when everyone tries to spend the least amount of time in the room and no visitors are allowed. Certainly we can relate to the comments that were shared because this continues to be a stressful time for ICU providers, but one thing that we noted were measures that individuals reported that were useful to them, and certainly as the pandemic continues, these may be useful for other ICU settings to adapt. One clinician responded that they added a full-time FTE just for helping staff with donning and doffing. Another identified that they made an infection prevention specialist hotline for 24-7 availability to field calls from clinicians regarding protocols. Another highlighted that they provided psychological support to healthcare staff by a spiritual coordinator within their organization. Another highlighted ongoing communications between hospital leadership and clinicians was so important, and then another highlighted that disseminating the most recent best practices with respect to managing and treating patients with COVID-19 in the ICU was also beneficial to their care. So we've heard reports from organizations on specific measures that they have implemented as a result of the pandemic in order to support their clinicians. This comes from Rush University in Chicago, Illinois, where they have put out regular communications to focus on wellness with respect to team debriefings that are held, with respect to courses and classes that are held to support clinicians with respect to yoga or exercise or mindful meditation, having an area where staff can go to debrief. They actually launched a center for clinical wellness as a result during this timeline that has quiet spaces for staff as well as availability to speak with counselors. They also put in a number of measures to showcase leadership support, which is so essential. So whether it was providing food to frontline staff and meals or visiting to really see what their needs were or providing such things as access to music or pet therapy. So really highlighting that there was administrative support and that is certainly an aspect that is helpful for clinicians. Now the Society of Critical Care Medicine along with the Critical Care Societies Collaborative has been looking at the concept of burnout prevention in ICU clinicians. And in fact, in 2016, they launched an official statement that was published simultaneously in all four of their journals that really was a call to action to address the prevention of burnout in ICU clinicians. And many of the measures that were highlighted address things that certainly are organizationally measured, such things as promoting a healthy work environment, having adequate team dynamics, having appropriate communication and staffing, limiting scheduling days in a row, having the ability to have self-scheduling, having support groups. And so this obviously came from the research literature and certainly this was pre-pandemic, but we see many of these measures being implemented in ICU settings today during the pandemic. As an extension of that work, the Critical Care Societies Collaborative then held a national summit to bring in 50 experts in different fields to inform the societies on measures to prevent burnout and also conducted a survey among their members with respect to measures that were being implemented. And this was published in February of this year, so certainly pre-pandemic of last year. So pre-pandemic, but measures that were reported to be instituted by organizations are such things as healthy food choices, the ability to have an on-campus exercise or gym facility, self-scheduling, ability to take respite days, to limit the number of days working in a row, as well as other measures such as classes, relaxation classes and such on campus. And so we see that these are definitely organizational measures that could be adopted as we continue with the pandemic. So in summary, I wanted to share a little bit about the ongoing work that we're looking at from the rapid cycle COVID-19 surveys that the Society of Critical Care Medicine continues to launch. And certainly we know the pandemic has presented challenges for ICU clinicians, so providing emotional, psychological, and institutional support along with sharing how organizations are mitigating burnout will be most useful to our ICU communities. So I look forward to the dialogue that we will have that will accompany this session as part of my other colleagues addressing different aspects of burnout, because certainly this is a key area of focus for ICU clinicians globally. Thank you so much for the opportunity to participate. I will miss seeing colleagues this year at the annual Congress, but we'll look forward to hopefully having a live one next year. So thank you so very much. Hi. Thank you all for being with us today. We're going to move into our Q&A session. Please feel free to write your questions and vote for other folks' questions so that things will move up that are more important to people. We still have about 45 minutes or so, so we'll go until we run out of time or until we run out of questions. I'm actually going to take my moderator's privilege to ask the first question. I'm very excited we have some leading authorities in moral distress here on our panel, so I wanted to ask both Mary Faith and Beth your thoughts. There's been a lot of work in training healthcare ethics consultants, and there's a range of training programs now and resources. Now we have national certification of healthcare ethics consultants, but I haven't seen nearly as much about training for folks to lead moral distress services, and I know that you're both really national leaders in that area. I'm wondering if you'd take just a few minutes to fill us in on sort of if we or if other folks in our institutions wanted to get education and training in doing moral distress consults or developing a moral distress consultation service, how would we do that? Thanks, Alex. That's a great question. We just recently in the last couple of months put together a national moral distress consultation collaborative. Currently there are six moral distress consultation services across the country in this collaborative, and one of our key goals is to create a core curriculum for training new consultants and also helping institutions develop moral distress consultations. Until that's ready, Mary Faith and I have done multiple visits to organizations interested in doing that, so we're willing to still do that until the core curriculum is ready, but that is on its way. Excellent, thank you. I'm going to start moving to the online questions. Our first is a comment from Amanda. Maybe if we make employee burnout moral distress results part of the executive leadership team's evaluation, we'd start to see more chief wellness officers in health organizations. That's my hope. Would anyone like to comment on that? It's certainly something that we're seeing nationally even before the pandemic, but now with all that the clinicians are experiencing on an ongoing basis, it really is a priority and it should be a mandate. Mary Faith, you were going to say something. I couldn't agree more with what Ruth said. I think it needs to start from the top down, and that's the Board of Regents or the Board of Visitors, whatever board the CEO of the institution reports to, and then it's part of the metric for that person and then for all the other members of the executive leadership. Otherwise, things for the most part don't change unless you've got some seriously good leadership on board. Excellent. From Lillian, employee wellness health programs which allow credits or monetary rewards for healthy lifestyles could be implemented for healthcare providers in terms of mental and physical self-care participation in team trainings. This would require financial support from any administration, time for providers to participate. Are there movements for health insurers to see that maintaining the health and mental wellness of healthcare providers is a priority for future budgets? I have no information on that. Do other folks know or have thoughts about that? It's a great idea. I think it's a great idea, too. The only caveat there is that there's not too much, again, the idea of moral community, that there's not too much emphasis put on the individual as opposed to our collective responsibilities to one another. It's hard to be well in a system that isn't well. Well, and that's true. Clinicians have said that there may be an exercise facility or break rooms, but they don't have time to partake in that. It really has to be more than just providing these services, but there really has to be a commitment to have clinicians have the time to participate as well because it's not individual responsibility. It's the organizations. I would agree. One of the pictures in my head when we talk about moral distress is that when you're morally distressed, you're banging your head against the wall, right? Then you bang and you bang and you bang. You can put a pillow there. The institution can have yoga classes and the institution can have yoga classes and resilience classes and that kind of thing. All of that is well and good, but you're still banging your head. It might allow you to bang your head against the wall just a little bit longer, right? The problem is still there. I think wellness and I'm committed to the idea of wellness. I think we have to be very careful about what it can resolve and what its point is. From Amalia, should we call this avoiding conflict when we manage competing priorities of different stakeholders? Conflict, managed well, is good for the team. Perhaps we should instead describe it as addressing conflict. It's not good for anyone and contributes to moral distress of staff and families if we just sweep it under the rug by avoiding it. Agreed. Good point. From Richard, institutions are contributing to our burnout because of their over-concern for liability. What are your recommendations to bring reality to their fears? In other words, to get hospital leadership to focus a little less on liability and more on patient care? There's a long, long literature over the past 20, 25 years that shows how risk-averse we are and how actually, infrequently, there are successful causes of action that are brought for things like withholding or withdrawing life-sustaining treatment when it's not medically indicated, those kinds of things. I think part of it is acculturating our young clinicians as they are coming up. One of the things that we see, and I know you, Alex, those of us who do ethics consultation, see all the time is that often when we have an ethics consult, the real question is, can I be sued for this? And that people are practicing defensive medicine. And one of the things that any healthcare law attorney will tell you is, if you practice defensive medicine, you might as well put a sign on your back that says, sue me now, right? You want to be practicing medicine and nursing and all of the professional health arts according to the standards of care. And so I think that there's just, it's actually, I think, is at the level of an urban myth, right? That you can be sued, you're going to be sued for these sorts of things, when really it just doesn't happen that often. So I think part of it is just starting with educating young clinicians and others moving forward. Beth writes, in regards to breaking down barriers, I think a big issue that remains is getting all teams' attendings on the same message. For example, patients' neurologists versus the ICU and palliative care attending. How do you suggest resolving conflicts between leaders of the team? Well, I'm going to take a stab at that. So I will say, because this is something that I've worked on a lot. So, you know, one of the things that we talk about a lot is getting the team on the same page before we start talking to them. I think that's really important. We tend to focus a lot on the ICU team, but that, because we've kind of done a lot of work already with our consultants. But sometimes consultants aren't yet really brought into the fold. And so developing systems so that consultants talk with the primary team, particularly the attending of record, before making recommendations to the family can be super important. Because we've all seen cases where folks from other services will come in and say things that are very different than what the family's been hearing. And that is so counterproductive. And letting folks know that. Letting folks know that that's counterproductive and that it has caused problems. It can be difficult for consultants to hear that and think that they're the ones who cause problems, but they do need to hear that. Because that's how people learn, you know, what things are helpful and what things aren't. And be interested to hear what other folks think as well. Alex, is there consensus about that kind of approach to consultation? We've run into that as well. And some consultants seem to really agree with that. And others say that they, you know, they have every right to talk to the family. And so, which they do. And they don't necessarily agree that they're doing the consultation to inform the team, right? So, I was wondering if you know about what kind of consensus there is, or what kinds of guidelines there are for consultation? I haven't seen guidelines. I'd be interested to know Doug's experience. Because I will say, in my experience, I've been very clear with consultants that they're consulting to me, not to the family. And that I need them to talk to me before they talk to the family. And I haven't received pushback. I've had a couple of surgeons say, well, usually I talk to the family. And I would be very nice about it. I was like, look, I just really appreciate it if you brought it by me first. So, I know what you're going to say to the family first. And maybe we can go in together so that I hear exactly what the family's hearing. And let me fill you in a little bit. And that's worked really well. But I'm also a pediatrician, right? And so, things might be a little different. Doug, what's been your experience? Alex, I like the way that you've framed the response. When I talk with folks about this and hear some strategies, one strategy that some clinicians have advocated is to really wall off the family from other opinions outside their own. And that makes me nervous. And what you articulated was a much more nuanced approach, which is to say engaging with, for example, the surgeon and saying, you know, I'd like to understand your perspective on this so that I either know what you're going to say to the family or we can talk to them together. And I think that's respectful both of the other clinicians' expertise and also of, you know, a reasonable range of disagreement in cases that does sometimes come up and that I think is important to share with families or patients as an honest appraisal of differing views on a hard case. Alex, one of the things that this is not original to or unique to UVA but that we started several years ago is what we call a complex care approach to patients who are complex for various reasons. And one of the definitions of complexity is that there are a lot of consultants caring for this patient. And sort of the nut of it is that the entire team, and by team I mean not only the primary team, you know, all of the multidisciplinary folks on that team, but all of the consultants as well, come to an initial meeting and there is consensus about the plan of care based on realistic goals of care. And often there is a person identified to communicate with the family. And perhaps more importantly, there is a place in, you know, EPIC or whatever you're using for your electronic medical record where that consensus and the plan gets posted so anyone who's participating in that patient's care knows where to go. And so that everybody's on board. I mean, it's a pretty simple thing but it can be really effective. And that group defines for itself how often do they need to meet and so forth. But you kind of don't leave the room until there's consensus about a plan of care. I mean, that sounds like a great idea. I'm trying to envision how do you get all of these people from all these different services all in the room at the same time. Logistically, how does that work for you? Well, you know, we started out in our critical care units. There are a number of acute care units who do it now too. Generally, the people who organize the meetings are, you know, senior nursing leaders on the units, the clinical nurse specialists, others. And you know, we haven't, maybe except for one unit, we have not had pushback. Actually, that unit's doing it now too as well. And I think that maybe word has gotten out. So we started it as a pilot in one unit and it, you know, it morphed into other units after that. Vincent writes, hospital administrators are currently only concerned about solving the financial impact of COVID-19 in their institutions. Many institutions are cutting expenses by eliminating low-paying support positions and increasing the workload on nurses and physicians. Their last priority is employee burnout. Ruth, do you have some thoughts about that? I know you've been working a lot in this area. Yeah, I would say that that is definitely changing. You know, the pandemic has really brought more clear focus on the problems that clinicians face in the ICU. And currently, the pandemic has exacerbated that, right? So I mean, leadership is keenly aware of the issues with now trying to support staff that, you know, the messaging has really been heard, at least, you know, in my experiences of the places that I'm affiliated with, that that is, it's a clear message now where leadership is keenly aware of the importance of supporting staff, especially as this pandemic is ongoing. And if anything, you know, the public is aware of it as well. This is the first time we have ever seen as much TV coverage of intensive care units ever, right? So people are really aware. You see news media, you know, New York Times series, articles written even in local papers about the importance of supporting staff and this strain that ICU clinicians are undergoing. So, you know, hopefully, this will lead to enhanced efforts to support staff and not just, you know, during the pandemic, but on an ongoing basis. So I think we need to have organizations really embrace this as a key area to focus in on going forward, whether that's our own professional organization, entities such as, you know, American Hospital Association and others, you know, this really, and the work, the ongoing work of the National Academy of Medicine, I was delighted to see that they're extending their clinician resilience initiative another year because of the pandemic. So hopefully, you know, highlighting this to key stakeholders will continue. Alex, could I ask a question? Please. This is for professors Marshall and Epstein. So one of the things that I both really appreciate about the notion of moral distress and struggle within practice is, I guess, for lack of a better term, what I might call problems with incorrect ethical certainty that drive clinicians. And so what I mean is, for example, sometimes a clinician has a very, very strong opinion that something is ethically wrong, or, you know, that they know the correct ethical course of action, and they believe that it's not being taken. And yet, sort of when you take a broader step back and look at the range of what's permissible, according to current standards of care, you know, normative standards of care, it, what's being requested by the patient or family is within that, and yet the clinician really objects to it. So how do you work with the tension there between one's own individual ethical compass, and more broadly, what might be permissible? That's a great thing. And we, great question. We, we do run into that. When we do our moral distress consults, we love for them to be interprofessional so that we get lots of different perspectives, because you're right, people do come into this, these kinds of, you know, aggressive, they see a patient undergoing, you know, enduring aggressive treatment, for example, in the ICU, and the patient is, you know, seeming to go, you know, not improving and not getting worse, and going nowhere, like, and so, and so clinicians kind of form an idea in their head about what the right thing is to do, so that when we get together and do a consult, the interprofessional dialogue really highlights the fact that there is this spectrum of ethically justifiable action, and maybe it's not what you would choose, but it is actually, you know, within the realistic choices, right? So, but, but often, more often than not, and I would almost say always, but always is a big word. There's some, there's something, there's something bothering those clinicians, that, that does smack them as, as ethically wrong. And if you kind of, if you dig a little bit deeper, you can say, okay, well, you know, maybe transitioning to comfort care, for example, isn't exact, isn't obviously the right thing. But what other kinds of things are bothering you? So the patient is suffering, right? So that is morally, I'm, I, as a nurse, or you as a physician are obligated to address unnecessary suffering. And if we're not addressing that, that's, that is a source of moral distress. So that we can deal with, right? The idea that, you know, these kinds of patients, you might see nursing staff, like bargaining, I'll take care of them today, but you take care of them tomorrow, because this is really emotionally draining for me, sets up, it's, you know, it's a way to circle your wagons and self-preservation, but it's also creates real discontinuity. So nobody really knows the patient or the family. And so that could be a source of moral distress as well, that really nobody knows this person as a person, and what would they want? We wouldn't even know, because I took care of him three weeks ago, and now I'm taking care of him again today. So addressing discontinuity might be a way to address, you know, that might be the source of moral distress. So even though the right ultimate action may not be ethically clear, there might be professional obligations that are being kind of violated in the, in the, in that middle space, right? So like suffering and poor communication patterns and poor collaboration or, you know, that kind of thing that we're not, something that we're not doing that really kind of gets people's guts going, like, something's not right here. So yeah, does that, does that help? Yes, thank you. Good. Okay, did you want to? I didn't, I don't have anything to add. Thank you. Beth writes, what is the minimum the nurse charge can do each day to check for burnout in her nurses? Sometimes I think the key is recognizing and doing something, even if just listening, before the employee totally breaks down. Yeah, I mean, from our last straw study, the, the idea of mattering, really feeling like you, you do matter to people, was so, was so obvious, it was so important. And so I would just acknowledging the work that people are, are doing and, and thanking them, thanking them, not necessarily, you know, on a, in a shallow way, but just kind of acknowledging the fact that that particular person is worthwhile and needed on the unit and genuinely valued. I think that might, that might help. So another thinking, you know, that often moral distress is, it's not like, you know, sort of the normal issues that come for clinical ethics consultation that I'm not sure what to do in this situation. I mean, moral distress happens when you think that you know, what the right thing to do is here, here is, and there's an external constraint or an internal one, like fear of reprisal, that, that prevents you from being able to do that. And that gets translated into, I can't do the right thing. Thus, I'm doing something wrong. And we've used over the years, the data that we've, that we've gotten from our moral distress consultations and our research, and we've really put it into play and policy development. And so I won't belabor this, but in our code status orders and associated treatment plan policy, you, you don't see the word attending physician in that policy. You see the word healthcare team. And the healthcare team is defined as the attending physician, the LIPs, the nursing staff, the respiratory therapists, and other clinicians who are going to be the ones at the bedside attempting to resuscitate that patient. Because we all know the data are that generally it doesn't work, at least in terms of survival to discharge. Same thing with pain management that you mentioned, Alex. So our policy has that very same policy and our medically and ethically inappropriate treatment policy have caveats in there that say, unless you've got a capable adult patient sitting up in bed saying, you know, I believe in redemptive suffering and I don't want that, those opioid medications, right? No one, right, other than the team, you know, prescribing according to standard of care can decrease that patient's pain medication. So you don't, you know, so we don't at our institution, family members don't get to come in and say, you know, I want mom or dad to be awake and alert when I come to visit because that's a clinical call. And, you know, that's something that we know from the physician perspective, the nursing perspective, healthcare team perspective, is, you know, these are cases that bother them. So we built those in. We've learned over time, we've got a really supportive administration that's done this experiment in moral distress consultation over the last 16 years. And that's one way that we get at it at an institutional level that helps us perhaps prevent some of the things or mitigate some of them at the unit level. Yeah, actually ask a follow-up. So, you know, during Beth's talk, she was talking about hospital leadership and the importance of hospital leadership really valuing the staff, right? And the fact that when people don't feel valued by hospital leadership, that's a big indicator. I'm wondering if hospital leadership is, isn't perceived as really valuing those. What can unit leadership do that, you know, unit leadership can't really change pay and oftentimes can't do some of the things that hospital leadership can do, but oftentimes unit leadership can do a lot to sort of help them. And given that a lot of folks who are participating today may not be hospital leadership, but may be unit leadership or may be able to influence their unit leadership. I'm wondering what folks on the panel think are some of the key things that medical directors, nurse managers, or nursing directors, or other unit-based leadership could do to really make a difference for folks that are just opening up. Yeah, just the basics of having staff meetings with discussions and no agenda. You know, people need to share how they're feeling, what they're doing, what could be improved on the unit. We share at one of our sessions that they incorporated sending an email to staff on their birthdays. And that one, he attributed that one initiative as really helping to form a bond. You know, he as the director did that for all the staff and, you know, he made sure that he outreached to everyone, regardless of their role, even the, you know, the cleaning personnel who were in the unit to really, you know, have some touch base on a, just on their special day, you know, hoping you're having a special day, please know you're appreciated. And I thought, well, that was, you know, a really nice example of the tone that the leadership can place. I would agree with that and add wholeheartedly with that. And also add that staff know when their when their leaders are advocates for them. So we've heard lots of stories where the medical directors on units have been just trusted, go to people who will at least try to advocate for the will at least try to advocate for the kinds of kinds of problems and issues that arise on a unit. They're really, they're defenders, whether or not that they can fix the actual problem. You know, is that's one thing, but just knowing that your medical director or nurse manager will add to advocate for you and has your back. I think that's really helpful. Great. Unfortunately, Dr. White is on service right now in the COVID unit and had to run. So I'm sorry to everyone for that. But we're going to go ahead and continue as long as we have questions and we have time. Jose writes, would you please share your experience with end of life discussions with minority healthcare groups that have strong religious beliefs against changing goals of care, especially in patients receiving ECMO support? What has worked well for your team? And I have something to think about. No, no, no. I was just going to say, probably you have, you can speak to that. So I will say one of the things that works best for these families is helping the team understand that sometimes families are right and teams are wrong. That's one of the things that can really work best. We were talking, you know, Doug had brought up this point, like, what do you do when clinicians feel like they really know what's right, but what the family wants is within the range of permissible choices. And this is exactly that type of situation where there's a broad range of what is within the reasonable range and different families have some really different thoughts. Like that one case that I had presented in the talk where a child had an exam consistent with brain death and yet the family was very opposed to that. And that's sort of one of the most extreme cases, right? But we see cases like that. And what we then do is we help the team understand why is the family and how do they find meaning in this? And how can you find meaning? Because frequently there are a ton of data that show that ICU doctors, ICU nurses, and other folks who work in the ICU are much more comfortable terminating life-prolonging interventions, undervalue the lives of people with disabilities or chronic medical conditions, underappreciate the burdens of pain, but also undervalue the lives of a lot of our patients compared to what their families value them. And then when you look at persons with disabilities, it's amazing because they value their lives on average far more than even their families, which is far more than the physicians and nurses. And there are a lot of data that show that. And so helping teams really understand that and understand that just because we think we would never want this for ourselves and we would never want this for our family, that doesn't mean that we're right. That's really just our opinion. And as long as the family is making a choice that's within the bounds of reasonable decisions, that they have a right to do that. And then we help them with that. And we talk a lot about shared decision-making models. And I encourage folks who haven't read the SCCM and ATS policy statement on shared decision-making in the ICU to do so. There's a lot of different ways we can do it and we can be very involved or not so involved in the actual decision-making point, but really respecting the broad range of acceptable choices. So that would be my perspective, but I'd be interested to hear what others. You know, one thought, our suggestion perhaps is also to look in the literature. So I'm thinking about, for example, honoring family members or surrogates or patients for religious perspectives. And, you know, as an ethics consultant, especially in decision-making at the end of life, one of the things that we often hear is that the patient or the family members or the surrogates are holding out for a miracle or they're waiting for a miracle. And the American Journal of Bioethics, which is an excellent bioethics journal, had a couple of years ago a target article about responses or how to think about when families, you know, are holding out for a miracle. And the format that AJOB, American Journal of Bioethics, uses is that there's a target article, but then there are invited or non-invited responses by, you know, a variety of, you know, anyone could ask to write one. And so you get perhaps almost this 360 view on how to approach that particular problem. So how do you think about someone's request for a miracle and how do you respond to it? And so that's a, you know, just one example of saying also look in their literature because there's probably something about it in there from the last 30 years of work in the world of ethics. Great. Lillian writes, what is the one thing from each speaker that you would hope would be changed in the structure of healthcare delivery that would make the most difference in moral distress, ethical challenges, burnout, and wellness? Many of us serve in our local communities to try to improve our ICU teams, departments, our healthcare system. What is one thing each of you hope for us to work on in these domains? I'm going to go around. Ruth, would you like to start with that? What's the one thing you would like to see changed? I would say having an ICU culture, you know, changing the culture within the ICU so that we truly embrace the team and that's in all aspects. You know, how is the team functioning emotionally, physically, you know, the whole gamut because that is an important aspect. I would wish for organizational leaders to recognize that the more you empower your workforce, the better, the more they're able to work to their maximum professional capability and provide the highest quality care. So power is not finite and share it. I would probably say universal healthcare because we would, that would preclude a lot of the injustices that we see in healthcare and perhaps more balance between access to health, right, and relative to winding up in an intensive care unit as a result of non-access, which happens too much of the time. And Alex, what would you say? Yeah, so I'm gonna get back on my soapbox a little bit, which is I think the one thing that institutions across the country need to make an enormous shift would be to get away from this idea that good people with good intentions are consistent, should be doing ethics consultations. I think that's a major problem that we've seen across the country. Ethics consultation is a field unto itself. It takes education and training. There's now national certification. There's, you know, almost 400 folks who are certified health ethics consultants. I think one thing that everybody can do is go to their hospital leadership and say, we have a lot of big problems. We have moral distress. We have need for, you know, guidance from ethics consultants. And even if we can't afford as a hospital to hire a full-time, educated, certified healthcare ethics consultant, we need a way to reach out and get help when we need it. And I think that would make a huge difference because I have personally seen how helpful a good healthcare ethics consultant can be. And I have definitely seen how dangerous it can be when people who are not trained and not educated are doing the work. So that would be my. Amy writes, wellness programs are great, but how do we get leadership at all levels to be accountable for the overwhelming burnout and turnover due to this? When we go to leadership and repeatedly tell them what the problems are, but they're never addressed. This is what makes people want to leave and find a place of values. Yeah, I think the importance of communicating, you know, to, to leaders and it's a, you know, the unit leadership needs to be communicating to the hospital leadership and making it clear. It's got to be a priority, you know, especially because of what we're seeing as a result of the pandemic. And I think because of the staffing concerns and the ICU capability to care for patients during the pandemic, that has really raised a flag among hospital administrators because they actually are seeing, you know, the impact of their ICU resources. And if they have short staffing and they're, you know, have not able to take more patients, their community that has come to the attention of their communities here in our state, the mayor every day, you know, puts out a notice in terms of how many patients there are. And the, even our community leadership knows, you know, what the bed capacity is. And so it really has, I think been brought to more heightened attention and hopefully that the leaders now know the importance of addressing that. So I, I'm going to say, I agree with you, Ruth, but I'm going to say, I'm going to revert back to what I said in my, in my talk, until the board, the board of it, until the highest echelon of institutional leadership or university leadership, or, you know, whatever your institution is, until they hold the CEO accountable and there are metrics to do it, it's not going to change. And why do I say that? I say that because eating you're young, which is what we do. And I think we do it, especially in critical care has been around since critical care began. And it's an unfortunate thing. And the managers on the units are the ones who, you know, kind of bear the brunt of that because they're stuck in between. And until there's a way to do that, then, you know, institutional leadership, then, you know, institutional leaders, they are going to grind whatever grist the note requires. And I'm sorry to say that, but I think that's the truth. And that's the only way to change things. It didn't start with COVID. It's been around since the beginning of the advent of critical care. That's thus the notion of law community. Beth writes, we had a case where the decision maker for a patient was her 16 year old daughter, who was her own family. She was very mature for her age and appeared to know what her mother's wishes were. But there was concern among the staff members if this was just too much to put on her shoulders. She had to make the decision whether or not to intubate her mother with cancer, who did not have mental capacity. It was also a question of legality given the daughter's age. I think that one's for you, Alex. I think that's, I mean, it's super difficult, right? So, so for, you know, so this is one of the things we always talk about is, is there's ethical issues, and then there's legal issues. And oftentimes they're different, right? And so having a solid healthcare ethics consultant and having a solid legal counsel are really important. And those two things are separate. So the issue of whether a 16 year old is considered to have legal competence to make decisions on behalf of her adult parent is one issue. A different issue is whether a 16 year old is considered of her adult parent is one issue. And different states will have different statutes that govern that. So that's certainly one issue. And then the other issue is, is this person a decision maker? And there are certainly, you know, data show that there are 16 year olds that have the decision-making capacity similar to an adult, right? There's some differences, but many can do a very good job. The issue becomes how do we then support a 16 year old? It's like, how do we support anyone who's making super difficult choices for a loved one at an ICU? And when that person's a minor, 16 year old, you know, that person is likely going to need even more support than other people. So I think it can be reasonable if that's the only person, you know, Doug was talking a great deal about how difficult it is to make decisions for unrepresented patients. If there's anyone that can help us make decisions, that becomes really important. One of the things that might be very appropriate for a 16 year old would be really using more of a equal decision maker model, potentially even an informed non-dissent model so that that 16 year old can tell us about what it is that she thinks her mother would want. And then we can take the burden of making that decision and say, you can dissent. If you disagree, then we won't do that, but I'm going to bear the burden of making this really difficult choice so that you don't have to bear that burden. That's an ethically appropriate model of decision-making and that might be a really good one. There's lots of things. And then I only have one more question here. So this is going to be our last one. My perception is that when risk manager is called in on the case without any family or friends, we often have a very prolonged course prior to any withdrawal of care. Even when all attendings are in agreement and the process has been followed for declaring futility, sometimes needing a course prior to and the process has been followed for declaring futility, sometimes needing a court-appointed decision-maker. Does this fluctuate legally from state to state? So I'm going to start with that one. So first of all, we want to be super careful when we talk about futility. So SCCM and other organizations have agreed that the term futility should really only be used when we're talking about truly physiologically real interventions, in which case there's really no decision to make. So when we're talking about these kinds of issues, we're really talking more about potentially inappropriate interventions and we have mechanisms for thinking about that. And I think Doug's discussion really focused on this issue that sometimes slowing things down and taking time is really important because if we don't slow things down, we can sometimes miss things. And that's when implicit biases really become problematic and certain classes of patients end up receiving different care than other classes. So I would say slowing things down is not a problem. I think that was really important. It can become very frustrating for ICU teams because they think, well, obviously we shouldn't be doing this. Why do we have to go through all this rigmarole to get approval for it? But that rigmarole is really important to help protect patients and us as a society more broadly. Other thoughts? There is variation by state in how those kinds of things are managed. I think Virginia might be one of the only states that can appoint a decision maker. If you go through the app, there's an algorithm. And if there's no family, no blood relative, then a patient care consulting subcommittee, which is a subcommittee of the ethics consult service, can appoint a friend. But in Virginia, that friend that we have appointed cannot make decisions to withdraw or withhold life-sustaining treatments, which is a quirk of our Virginia healthcare decision set. However, and that sounds like it might be terrible. However, our take is that no patient should suffer a prolonged death. If there's team consensus and there really isn't a decision to be made, then that appointed friend isn't making a decision to withdraw or withhold. It's the only humane thing to do. I'll say I've interpreted the law to mean that if there's no good, hopeful benefit to this patient, and the team is in consensus that there's a terrible prognosis, then there's really no... I don't think that the law was intended to torture people. I guess that's what it comes down to. But I think it does vary by state, don't you think? I mean, it's not the case where you are, right? Right. And I think this again becomes important to have both good ethics consult services and good legal consult services, right? Because that legal team should be helping you really figure out what's legal and what's not. Absolutely, right. And that becomes very important. But with that, I'm going to wrap us up. I wanted to take a moment to thank all of you folks for participating in being here with us today. I wanted to really thank Professor Quinepell, Professor Marshall, Professor Epstein, and Professor White who had to step away for participating in this panel. I think it's been just great last two hours. I've learned a ton myself, and I've really enjoyed it. So thank you all very much. And I hope to all of you that you have a great rest of your Congress. Thanks so much. Have a great day. Thanks for the great questions. Thank you. Thank you, everyone. Come do the ethics, Keg!

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