Team Management of Long Term ICU Patients

Craig S. Jabaley, MDEmory University, Atlanta, GA

Disclosures

• I have no relevant disclosures.• No planned discussion of off-label drug or device use.• (I have a proclivity for bad stock images.)

Cardiothoracic ICUs 2020

• Less “bread and butter”• More clinical complexity• Proliferation of ECLS• Throughput problems• More readmissions• More chronicity

Kc, D., & Terwiesch, C. (2012). An Econometric Analysis of Patient Flows in the Cardiac Intensive Care Unit. Manuf Serv Oper Manag, 14 (1), 50-65.

Areas of Focus

• Clinical pearls• Conflict management• Family support• Bioethics and moral distress

Clinical Pearls

Common sentiments?

• “Why aren’t we moving forward?”• “Why isn’t the patient getting better?”• “Should we start some oxandrolone? Check a copper level?”• “No major changes for today.”

Major Clinical Challenges

• Therapeutic nihilism• Loss of information fidelity• Maladaptive cognitive processes

Therapeutic Nihilism

• What are the drivers?• Burnout• Limited therapeutic options at extremes of physiology• Increasingly frail patients• At times, futility

Therapeutic Nihilism

• What might we do?• Burnout

• Optimal mitigation strategies remain unclear• Limited therapeutic options at extremes of physiology

• Embrace uncertainty• Remain vigilant

• Increasingly frail patients• Calibrate expectations across the board

• At times, futility• Engage in shared decision making• Remain committed to treating the patient in accordance with their wishes

Therapeutic Nihilism

• "... I will apply for the benefit of the sick, all measures [that] are required, avoiding those twin traps of over-treatment and therapeutic nihilism."

Loss of Information Fidelity

• Challenge: Chronicity and complexitybeget information loss

• Consequences:• Inconsistent approaches to complex, prolonged treatment• Poor decision-making begotten by poor information• Lost individual and group time to information re-discovery• Poor perception by parties who may have more longitudinal insight

Restoring Information Fidelity

• Scheduled multidisciplinary table conferences

• Generating excellent clinical documentation

• Involvement of patient/family stakeholders

• Team compositions that ensure longitudinal oversight

• Appropriate utilization of high-quality consultants

• Routine multidisciplinary bedside rounds

• Individual-level, in-depth chart review

• Scheduled team subset table conferences

• Joint information handoffs

• Systems for longitudinal information retention

• Appointment of information stewards

• Routine clinical documentation

• Routine bedside rounds• Maintenance of detailed

individual records (i.e. cards)

• Routine individual provider-level handoffs

More Effective

Less Effective

Time Draining Time Sparing

Maladaptive Cognitive Processes

Maladaptive Cognitive Processes

• Two relevant quotes…

• "This is the essence of intuitive heuristics: when faced with a difficult question, we often answer an easier one instead, usually without noticing the substitution."

• "The confidence that individuals have in their beliefs depends mostly on the quality of the story they can tell about what they see, even if they see little."

Conflict Management

Jones et al. Ann Behav Med. (2016) 50:487–496

Jones et al. Ann Behav Med. (2016) 50:487–496

Is Conflict Always Counterproductive?

• Conflict can help (or may be necessary) to build relationships• If managed well, conflict can beget creativity• Conflict can be a sign of engagement/caring

Why Conflict Becomes Counterproductive

• Appreciation• Affiliation• Autonomy• Status• Role

(Core Concerns)

Core Concern Unmet when… Resulting emotions… Resulting behaviors…

Appreciation I am unappreciated Anger, impatience Negative reactions, work against true interests

Affiliation I am treated as an adversary

Indignance, disgust, resentment

Isolationism

Autonomy My autonomy is impinged

Guilt, shame, remorse Rigid thinking

Status My status is put down

Embarrassment, sadness

Deception and untrustworthiness

Role My role is trivialized or restricted

Envy, jealousy, anxiety

Core Concern Met when… Resulting emotions… Resulting behaviors…

Appreciation I am appreciated Enthusiasm, caring Cooperation

Affiliation I am treated as a colleague

Compassion, contentment

Collaboration

Autonomy My freedom to decide is acknowledged

Comfort, hope Creativity

Status My high status is recognized where deserved

Accomplishment, courage, proudness

Trustworthiness

Role My role is fulfilling Calmness, relief, relaxation, happiness

Productivity

Family Support

Real comments from a “chronic” patient’s family:

• As he got sicker, we didn’t see an increase in urgency• Physical exams became shorter and shorter• Our only source of continuity was his surgeon• Nobody wanted to put on a yellow gown• We were always there but not always engaged by the team

Real comments from a “chronic” patient’s family:

• As he got sicker, we didn’t see an increase in urgency• Physical exams became shorter and shorter• Our only source of continuity was his surgeon• Nobody wanted to put on a yellow gown• We were always there but not always engaged by the team

Sources of Family Distress

• Financial burdens• Personal burdens• Structural burdens• Healthcare surrogacy• Frequent changes in the care team• Uncertainty• Inconsistent messaging

Sources of Family Distress: Potential Solutions• Financial burdens

• Establish/understand/offer means of financial support• Personal burdens

• Acknowledge and encourage self-care• Structural burdens

• Institutional partnership• Healthcare surrogacy

• Targeted information delivery, anticipate and prepare for difficult discussions/decisions• Frequent changes in the care team

• Restructure the team if needed• Uncertainty or rudderlessness

• Acknowledge and embrace uncertainty• Inconsistent messaging

• Promote communication within the team, any meetings require homework

Moral Distress

Does this sound familiar:

• “What are we doing here?”• “Why are we doing this?”• “Why won’t they let him/her go?”• “Has anyone talked to the family?”• “Why aren’t they getting it?”

Guiding Principles of Modern Bioethics

• Autonomy (or self-determination)• Of thought, intention, and action• Decisions free from coercion or coaxing

• Justice• Burdens and benefits of new/untried treatments must be equally distributed

among all groups in society

• Beneficence• Intent of doing good for the patient involved

• Non-maleficence• Intent of not doing harm

What is moral distress?

• “Moral distress occurs when a clinician makes a moral judgment about a case in which he or she is involved and an external constraint makes it difficult or impossible to act on that judgment, resulting in ‘painful feelings and/or psychological disequilibrium’”

-Jameton 1984

• Well described in bedside nurses• Only more recently appreciated amongst the rest of the care team• Often exists even in the absence of patient-level ethical tension

Sources of Moral Distress

• Delayed end-of-life discussions (i.e. ECMO)• Delayed or poor decision making (i.e. inadequate surrogates)• Medically inaccessible or inappropriate care• Poor communication surrounding brain death• Codes gone wrong• Health disparity cases• Psychiatric issues• Grieving family members

Moral Distress: Potential Solutions

• 24/7 Clinical ethics consultative service• Preventative rounding• Debriefings• Schwartz Rounds (i.e. ethics grand rounds)• Development of a virtuous atmosphere

• Trust between clinicians and families• Empathy and humility

• Deliberate communication: rapport, preparation, targeted questions, active listening, reflective feedback, clarity, targeted silence

What is a Good Death?

• “…one that is: free from avoidable distress and suffering for patients, families and caregivers; in general accord with patients’ and families’ wishes; and reasonably consistent with clinical, cultural, and ethical standards”

-IoM

Summary

• Clinical pearls• Recognition of therapeutic nihilism• Restoration of information fidelity• Redirection of heuristic reasoning

• Conflict management• Valuing productive conflict• Managing unproductive conflict

• Family support• Treating the second victim

• Bioethics and moral distress• Treating the third victim

Thank you!csjabaley@emory.edu