Thank you. I may intersperse this with a little humor. This is not a happy topic. But I'm going to start out by talking about the 1984 Detroit Tigers. Does anybody remember them? A couple people do. Yeah, a couple people here weren't even born in 1984. But I was. And you'll see Alan Trammell there. So Alan Trammell. I think that might be Willie Hernandez, too, in the middle. Alan Trammell was a great infielder along with Sweet Lou Whitaker. And they had a guy on their team named Tom Brookens. And he filled in very ably, usually. And so I'm a little bit of a utility player. I'm a replacement here today. I'm the Tom Brookens. And hopefully I'll do as well as he did. Go Tigers. We have quite rightly, and this is a team from UCLA, I think, the ICU survivorship team from UCLA. So we've quite rightly emphasized survivorship in recent years. There's been a strong movement to support the needs of ICU survivors. And we have an ICU survivorship clinic at Vanderbilt. There are perhaps 30 or 40 of them around the world. There's one at UPMC. There's one in Utah. There are many now around the world, around the United States. And it's great and it's proper. But I think sometimes, even as we have focused on survivorship, we have perhaps focused somewhat less on the impact of family members who lose a patient. We talk a lot about the impact of family members of ICU survivors. We look at rates of PTSD in this population, et cetera. But I think what we don't talk about so much, and I think we probably need to emphasize it a little bit more, is what happens exactly to those family members who are grieving, who don't get to see you in the ICU survivorship clinic because their loved one didn't survive. What happens to them? In some cases, they're well-supported in the context of a palliative care model, where everyone has known, perhaps for some time, that the patient is headed toward dying. But in other cases, it's not like that. In other cases, it's much more abrupt. I used to watch pro wrestling. Any pro wrestling fans here? The Detroit Tigers fan is the same as the pro wrestling fan, so that's good. And I used to love the Road Warriors, if anybody remembers them, Hawk and Animal. And they had, this is maybe the first time that Hawk and Animal have been mentioned at SCCM, but they had this move, which was a clothesline. And somebody would bounce into the ropes, and they'd come running across, and Hawk would take his big arm and he would give him a clothesline. And the guy's feet would get knocked off and he'd land on the ground. And often, when people die in the ICU, to make this somewhat more serious, it isn't that they've been walking with palliative care providers. It feels a lot more like a clothesline. That is, it's sudden and abrupt. There's no planning. There's no preparation. And in that context, it's really difficult, because that family member passes away, the patient passes away, and then that family member is headed back to wherever they go. And often, the people that got to know them well, the ICU team is a team of people they're not going to have any more contact with. They'll go back often to the small town that they were life flighted to the tertiary care medical center from. And they're really alone. They're really alone and left to their own devices. And we have support groups. I'm getting ahead of myself. We have these lovely support groups for ICU survivors. And we have a support group at Vanderbilt. We have one for family members of ICU survivors. And again, that's right and that's proper. But we really don't have many resources for the bereaved, grieving individuals who've lost family members in the ICU. So let's talk a little bit more about this. As I noted, there's no parallel emphasis on bereavement. And I think this is a real problem. Because what we know, and I think what other people may mention, is that outcomes in the context of the bereaved are influenced a lot by things like how well you engage them in the process, what kind of support they receive in the process. All of those things influence outcomes. And what we're lacking is a formal infrastructure, formal processes, best practices in the ICU related to bereavement. And people, I think, are really flying blind. And it's concerning. As I said, in the context of palliative care, there's this tremendous support. But if they're not involved, often people are left to their own devices. So what do we need? I think we need more integration of chaplains. We need more integration of clergy. We need more integration of social workers. We need more integration of psychologists. This is my colleague, our colleague in that picture, Dr. Erin Hall. I don't know if she's in the audience here today or not. But she's a psychologist from Geisinger, and one of the few, actually, that is fully integrated into the ICU, fully integrated in the ICU. And she does an amazing job. But you can't clone her, right? There aren't many of her. And the psychologists who are involved typically are involved in the post-ICU space, again, important, much more than they are in this immersive ICU space. So the way we're going to solve this problem, the way we solve most problems, I think, is the systemic approach. And it is going to involve more integration of mental health professionals. But what I would say is this is not a one-size-fits-all situation. You'll see an elephant and a stork and a snake there. They're not wearing the same size clothes, right? What's the point? The point is that the needs of families in the context of bereavement differ really, really widely, which is why one approach that has been articulated is called a three-tiered approach to bereavement. And that references the fact that, for some people, the loss of a family member in the ICU is profoundly traumatic. And for others, the loss of a family member in the ICU could be the end to a really rich life, to the end of suffering for someone who lived a life well-lived, imbued with meaning. And the difference in trauma, the difference in outcomes in those situations is very, very different, right? So when we look at PTSD rates in ICU survivors and the impact of the ICU on the development of PTSD, typically what we see is that people who are relatively younger have higher rates of PTSD. And that's not surprising, right? Because if you're 35 in the ICU and you're confronted with the prospect of dying, you've got young kids at home, et cetera, your experience of that is going to be very different than it is if you're 91 in the ICU, right? And frankly, you're ready to go, right? So I think we need to resist the idea that these clinical situations that we face are going to be remotely identical because they're not. In some cases, a nurse, in some cases, a family member is very well-equipped to support that family, right? In some cases, though, it does require the Aaron Halls of the world, the psychologists of the world, the social workers of the world, the experts of the world. In some cases, it requires a professional but not necessarily a specialist. It's clearly not a one-size-fits-all, right? And part of what we need to do here, I'm going to move ahead here. Bear with me. I'll move back. So this is called the anger iceberg. And this illustrates a point. And my point really isn't about anger, but this is the best way I could describe it, right? So when you see an iceberg, I don't know if anybody has been in a cruise ship that drove by an iceberg, but you see the part above the water, right, and then maybe you see a little below the waterline. But the bulk of that iceberg is way below the water, right? It's way below. You can't see it. You're probably going, yeah, what's the point? Here's the point. The point is that as it relates to death and dying and grieving, a lot of our behaviors are shaped by our own experiences and attitudes that are way below the waterline, right? So if we've had experiences with grief ourselves that are complicated, we may approach it one particular way. If we've had particularly painful experiences with grief, we might avoid walking into the pain of other people, right? So to be thoughtful clinicians for the bereaved, we've got to be aware of what is below the waterline. Does that make sense? What's going on in our own lives that is below the waterline? And as we develop heightened awareness and heightened insight, we're going to be more effective. And all right, I'm going the wrong way. Did I take us out here? Bear with me, guys. Luckily, there's only 11 slides. So all right, thank you. I'm sorry? I said I'm technologically useless. Oh, yeah, no, well, yeah, not compared to me. So two other quick things. One, as I noted, we have support groups for survivors of the ICU. We have so many of them. And this is a lovely development that has happened across the country and really across the world, especially since COVID. And we have a few support groups for family members of ICU survivors. We lead one every couple of weeks. And it's really meaningful and special. We don't have any support groups, though, for family members who have lost a patient in the ICU. And I think we should. Now, I'm going to go back to Vanderbilt. I'm going to tell my colleagues that. And they're going to say, seriously, they're going to say, Jim, oh my gosh, do you really want to add one more support group? And I'm going to be like, well, I do. I don't think it's a good idea. So we'll see what happens. Stay tuned. But the need is really great. I mean, the need is so great. And support groups are one way that we could care for those people who are grieving, particularly those who are in need, who are in this complicated situation where their grief is not resolving naturally. There are a lot of messages we need to send. But I think this is one. Sam Brown, who's going to speak later today, he is hugely erudite. And this is about as literary as I get Robert Frost. But Robert Frost famously said, the only way around is through, right? The only way around is through. And I think one of the messages we need to reinforce to families is not, hey, this is neat and clean and tidy. And we're going to tie it up in a bow. And it's all unicorns and rainbows. And you're going to be fine. I think the right message is, this is really a hard thing that's happened, right? This is a painful loss. This is a hard season. There's no shortcut, right? There's no panacea. It's just going to be hard. And as we are increasingly comfortable ourselves with that message, we'll be increasingly comfortable sending that message to other people. So thanks for your attention. Lovely to be with you today. Thank you.

family members

patient loss

ICU

bereavement support

mental health professionals