everyone and welcome. My name is David Shulman. I'm from the Emory University School of Medicine and I am here in the wonderfully privileged position to introduce our recipient of the Roger C. Bone Memorial Lecture in Critical Care. I have some prepared remarks and then I'll speak a little bit more about the wonderfulness that is Margaret Pisani. The Roger C. Bone Memorial Lecture in Critical Care was established in 1997 to honor Roger Bone, master FCCP, a leader in critical care sepsis and sepsis research. Dr. Bone empowered physicians to communicate with patients and families about end-of-life issues and had significant society achievements. This year is my extraordinary pleasure and privilege to present this award to Dr. Margaret Pisani. Dr. Pisani is currently a professor of medicine in pulmonary and critical care at Yale University School of Medicine. She's also the vice chief for mentoring and career development. Dr. Pisani's research in critical care has focused on delirium, sleep, and care of older patients. Her involvement with CHESS began when she was a pulmonary critical care fellow and had the opportunity to present her with research at the national meeting. She's been a member of the Scientific Program Committee, chair of the Women's Lung Health Network, and a member of the Critical Care and Sleep Medicine Networks. She's the current vice chair of the Council of Networks and actually shortly will be the chair of the Council of Networks and will join the Board of Regents in that facility. She's been highly involved in the Women in CHESS Medicine group. As a past CHESS grant recipient, Dr. Pisani takes pride in serving as a mentor to several trainees who've received funding from CHESS for their research and to those who've received recognition for their poster and abstracts at the CHESS annual meeting. Personally, I've had a chance to work intermittently with Dr. Pisani, but more importantly, I've had a chance to work with those who have worked under Dr. Pisani, both formally at Yale and more informally in mentorship. She has been an extraordinary resource both to the American College of CHESS Physicians and to a multitude of current and future leaders. Her work as a mentor and as a sponsor has been nothing short of exemplary. More recently, I've had the chance to work with Dr. Pisani in her role as leader of the Women in Pulmonary group and she's been part of a multi-society group we've been putting together to try to further the further the roles of women in leadership here. She is a firebrand. She is exactly the sort of person you would want to work with as somebody who is a mentor and I cannot wait to see what future things she brings both to Yale and to the college here. For her contributions to science and critical care medicine, I am pleased to honor Dr. Pisani today, so please join me in welcoming Dr. Margaret Pisani to present the Roger C. Bone Memorial Lecture. So it is a distinct honor to be able to give the Roger Bone Memorial Lecture in critical care medicine. This ward has been in existence for 23 years and the list of prior recipients includes giants in critical care medicine. I want to acknowledge that I am the first woman to give this lecture and I want to thank those who nominated me, believed in me, and supported me over the course of my career. I also want to acknowledge all the amazing women who are doing groundbreaking research in critical care, caring for ICU patients, and educating our trainees. I have no disclosures except that don't be upset with me. I am the chair of the ABI and critical care exam writing committee. Maybe don't all get up and walk out at once. Roger Bone was a world-renowned pulmonary critical care physician who authored the critical care textbook I used in medical school. I was familiar with his research on shock and sepsis. When I was asked to give this talk, my initial instinct was to speak about my work in delirium, sleep in the ICU, and outcomes in older patients. But as I started to prepare, I began by listening to an interview with Dr. Bone and reading the opinion pieces he wrote after he was diagnosed with cancer. His research over the course of his career was focused on understanding shock and sepsis and how we could best care for our critically ill patients by treating their bodies. But what I gleaned from his writing after he became ill was that he came to realize we were not doing our best for our patients if we did not address how to care for them at the end of their lives. So today, instead of talking about my research, I would like to share stories with you from my own experience as an ICU physician dealing with patients at the end of their life to illustrate the lessons I've learned from the patients, their families, trainees, and my colleagues in the ICU. I decided on critical care medicine as a specialty because of Dr. Joel Worth. I worked as an engineer before I went to medical school and had a bachelor's degree in physics and English and a master's in biomedical engineering. I was drawn to the ICU by the technology present there. Being an engineer, I was and still am very data-driven. I confess, it's hard for me to give a talk without slides filled with data. Dr. Worth was my attending when I was the MICU intern. Our team was busy. We had several patients who had died. I was feeling down and discouraged, thinking, who wants to do this for a living? There was a young man who we realized would not survive the ICU stay despite our best efforts. I had scoured the literature looking for anything that might make him better and expressed my frustration to Dr. Worth about our lack of treatment options. He told me that although we did not have any further treatment options, we still had work to do. Our job now was to make sure our patient was comfortable and that the family understood the prognosis. He assured me that we had the tools to make sure our patient didn't suffer during the dying process and importantly, our job was also to help the family. The family had to live with his death after he was gone. We wanted them to feel that they'd made the correct decisions about the next step, which was to withdraw care. That one conversation shifted my whole view of what it meant to be a critical care physician. In addition to the physiology and technology, I realized there was a very human component to ICU care that required acceptance of and the ability to convey uncertainty and also required you as the physician to be vulnerable. Preparing for this talk has given me the opportunity for reflection about how and why my career in clinical practice have evolved into what they are today. I hope as you listen to my stories, it will give you pause to reflect on why you choose this career path and what makes it both rewarding and challenging for you. This is me as an intern. My god, I look so young. Whenever I look at this picture, I'm like, whoa, you really are old now. Anyway, this was me as an intern with Beth, who was one of the ICU nurses. The cardiac care unit was my second rotation as a new doctor and I was working overnight. There was a woman who was going to die. She was admitted from the cardiac cath lab. There was nothing they could fix and she was in multi-organ failure. She had no family with her and the cardiology fellow in attending were standing outside the room just staring at the numbers on the monitor. We've all been there, right? Standing there staring at the numbers on the monitor. It seemed wrong to me that we would all stand outside her room and watch for the numbers to tell us she had died while she lied alone in the room. I started to feel upset, so I asked the nurse what she thought. She took me and we stood on either side of her bed and held her hands until she died. Thank goodness I asked the nurse because I was fortunate that early on in my training, I learned the importance of caring for a patient at the end of life. In that moment, Beth was my mentor, teammate, and collaborator. But as I reflected on this story now, with the perspective of over 20 years of hindsight, I realized I was able to ask this question because I'd experienced death before. I came from a large Italian family and my mother always took me with her as a child to visit sick and dying relatives. I spent lots of time in nursing homes and hospitals with my grandmothers and aunts and uncles. My prior experience allowed me to realize that something was wrong with staring at the monitors from outside the room while this patient lie alone. I had a sense that we should be able to do a better job caring for this dying woman. My hope with these stories is to convey several themes that I feel are important to the mission of providing end-of-life care. The first is that the words we use matter. The next is that we bring our whole selves to our work when caring for patients. There is no way to separate out our prior experiences and how they contribute to how we show up and our biases and we need to be aware of this. The next is that deep listening is important for making connections and connections are a prerequisite for building trust. Connections and trust need to be developed with the patients, their families, and all members of the team. As the folks at Michigan and now Hopkins like to say, it's all about the team. Finally, mentorship and role modeling are essential for training the next generation and also important for our individual growth. So some of you may know this gentleman Dr. Aaron Waxman. Dr. Waxman was my attending when I was a fellow in the ICU and he was one of the people who taught me the importance of choosing my words carefully when speaking with patients and families. He said we needed to speak in terms families could understand and to be clear about what we were trying to convey. I can still hear his voice in my head saying I needed to use the word dying. So often we use euphemisms to try to convey to families that their loved one is going to die. We say things like their blood pressure is low, their kidneys aren't working, the ejection fraction is only 20%, they have multi-organ failure. And while we know these things can happen on the road to death, families often do not. In preparing for this talk I came across this recent opinion piece entitled Reconsidering the Language of Serious Illness and I think it does a great job of conveying some of what Dr. Waxman was trying to teach me. They talk about how we use the words to need when we speak with families and that when we use the words to need it conveys that something essential is lacking. He needs a central line. If she doesn't make urine she will need dialysis. If she can't be extubated soon she will need a trach. As clinicians we can separate our clinical assessments of the need for intubation or dialysis from the deliberation about whether intubation should be done. But do families follow our logic and recognize the distinctions? And so the pattern of saying the patient needs something then backtracking into a discussion about whether it's best for the patients is a setup for miscommunication and downstream conflict. What the author suggests is using the phrase what this means. For example, your mother is getting worse. Can we talk about what this means and what to do next? What this means is an intentional pause for reflection without implying or presuming the appropriate course of action. What this means is a signal or a reminder that this change in health will have a major impact on the patient. And so when I'm thinking about meeting with the family I always start the discussion with an explicit summary of the patient's illnesses. Pausing to acknowledge the major health changes then creates space to attend to the patient's and family's distress before we start jumping to solutions. As physicians we're like always problem-solving. We want to fix the problem and come up with a solution. But before we do that we need to let families and patients process and absorb what's going on. And then what to do next frames an opportunity for deliberation. Space to consider what is acceptable to the patient. My parents were Italian immigrants. My dad had a high school education and my mom left school in the fifth grade to work during the Depression. No one in my family had gone to college and the idea of medical school was totally foreign. This is my dad. He joined the army at 18 and served in France during World War II. Then came home and worked as a carpenter. As maybe the case for many of you once I became a doctor my family expected I would know the answer to all things health-related. Both my parents had always said they wanted everything done to be kept alive. I never got into specifics with them about what they meant by everything. We always assumed my mom would die first. She was eight years into palliative treatment for metastatic breast cancer when my family was at my house for Christmas Eve. In good Italian tradition I made seven fishes for dinner and tiramisu for dessert. When people ask me what I would do if I wasn't a doctor I don't hesitate. I always say I would be a chef. This is my dad on Christmas Eve right here. He loved to garden and we had gotten him this like small enclosed like greenhouse that he could start his seeds in. Anyway so that evening my sister was driving my parents home and called me saying my dad was short of breath. I tried to get some history from her and told her to call 911. When the EMTs arrived my sister told them I was a doctor and they called me. They were having trouble intubating him in the field and they were going to transport him to a small community hospital. I drove to the hospital and arrived before the ambulance. They were still doing CPR and bagging when they arrived because they could not get an airway. The ER doc asked what I wanted to do. Should they continue CPR? The daughter in me was thinking of course we should but the doctor in me was running the possible etiologies of the arrest and the probable outcomes in my head and I knew that if he survived that he would likely have an oxygen brain injury and I thought this could not meet be what he meant when he said do everything. The phrase do everything often gives me pause when I hear it from patients and family members and it is one of the things I try to explore with them asking them to expand on this idea, talking with them about trade offs and potential outcomes. I'm not sure the ED physician should have asked me to make the call about stopping CPR on my dad but I learned from this experience. I wonder and worry about the burden we put on families. Is it too much? How do we balance burdening them with the entirety of all the medical decisions versus total paternalism? Do we ask them to make every decision because it is hard for us to say that we have tried our best and your loved one is dying despite our best efforts? Do we feel that death is somehow a failure on our part as physicians? Is it because of the uncertainty we feel uncertainty is a situation in which something is not known. It is natural and unavoidable part of life and all around us. When things are uncertain, it causes us to feel overwhelmed, stressed, anxious, worried, vulnerable and we tend to avoid those situations. One of the challenges of caring for patients in the ICU and especially at the end of their lives is not only recognizing they are dying but also being able to live with the uncertainty about our predictions. I think our uncertainty often leads us to offer care that may not align with patients wishes or that will not cure disease or provide meaningful recovery. It is hard for us as physicians to live with uncertainty. What if I'm wrong and they could survive? What if I miss something? Maybe there is another treatment. My mom was diagnosed with breast cancer when I was in college and had a radical mastectomy. Ten years later when I was a medical resident, she was diagnosed with widely metastatic disease when she presented with cord compression. I thought she would die in a short time. Ten years into her diagnosis of metastatic breast cancer on Memorial Day, my mom stopped eating. She would drink Gatorade but we could not get her to eat anything. My family asked me how long I thought she would live. I said a week at most maybe without eating. She lived two months. I of course lost all credibility with my family. Totally. They were like, all right, we're not asking you any medical questions anymore. You have no idea what you're talking about. And then the other thing was that we all thought maybe we should invest in Gatorade because it had some magical properties that we didn't know about. But anyway, this experience also taught me about uncertainty and being able to live with the unknown. So when families ask me how long I think their loved ones will live if we stop treatment, I tell them that in most circumstances we are not very good at predicting when someone will die, unless of course they are on multiple pressers with severe ARDS. And I use the story of my mom as an example. In my experience, one of the reasons we avoid end of life conversations is because we are uncomfortable with uncertainty. Acknowledging this when caring for patients may help us provide better end of life care and help us gain trust with patients and families. This leads me to vulnerability. Vulnerability is the quality or state of being exposed to the possibility of being attacked or harmed, either physically, emotionally, or materially. We are vulnerable when we talk about the mistakes we have made. We are vulnerable when we share personal details about ourselves that we normally keep private. And we are vulnerable when we are feeling difficult emotions. I posit that it's okay to be vulnerable and show emotion. And it helps us gain trust with families and patients when they see we care about them. While I would get emotional over losing a patient or a harder interaction with a family, I always did it in private. Many of you are probably too young to know who Simon and Garfunkel are. But my, well, maybe not all of you. But my much older brother, as I like to say, used to play their songs when I was growing up. And so the song, I Am A Rock, was actually my theme song during residency. I used to play it over and over in the car on the way into work. And so my kids actually got all the artistic talent. And so I'm not going to sing this for you. But you can see the lyrics. I am a rock. I am an island. And a rock feels no pain. And an island never cries. This leads me to Charlie. And this is the one story, if anything, out of all of them today that will make me cry. I took care of Charlie, who was a middle-aged man with cerebral palsy. His mom had cared for him his whole life. It was clear he was not going to live and leave the ICU. During my time in the ICU, I'd become close with his mom and heard her personal struggles and knew how much she loved her child. She made the brave decision to donate his organs after cardiac death. I stood with the nursing staff to clap him out to the operating room. And despite my best efforts to contain them, the tears rolled down my face. Later that afternoon, the resident on the team came up to me and thanked me for showing emotion. She said that they were taught to hide their emotions, that patients and families should not see them being vulnerable because then they would not trust them, trust that they could make decisions. That resident made me realize we needed to change the narrative that emotions equate to weakness. Our emotions are what make us human. They are our superpower. Brene Brown is a scientist who conducts research on shame and vulnerability. And here are some quotes from her work that I wanted to share with you. Vulnerability is not winning or losing. It's having the courage to show up and be seen when we have no control over the outcome. Vulnerability is not weakness. It's our greatest measure of courage. And I think it's doctors and physicians and caregivers especially, the next quote, show up for people in pain and don't look away. And finally, compassion is not a virtue. It's a commitment. It's not something we have or don't have. It's something we choose to practice. This leads me to Mary, Ali, and their family. While weddings in the hospital are a common occurrence these days, this wedding took place when I had been in attending for 10 years. And this patient and her family taught me the importance of good communication skills, knowing your facts, and rebuilding trust. Mary was transferred to us from an outside hospital with brain metastases and respiratory failure from lung cancer. It was in the documentation that was sent with her. I walked into the room with the patient and family, immediately expressing the gravity of the situation and the lack of treatment options. I assumed they had been told the diagnosis and prognosis. Well, you know what happens when you assume. They didn't say much, but later the social worker who had met with them came to find me. She relayed their concerns about my bluntness and shared that they had not heard the lung cancer diagnosis to my presenting it in such a matter-of-fact manner. I felt angry with the other hospital for not communicating to the family or to us, but mostly I felt shame that I had caused hurt to this patient and family during such a stressful time. Sarah, the social worker, gave me some good advice, and I went back to this patient and family to apologize and start over. I listened to their frustration at the delay in diagnosis, their fears, and their dashed hopes for the future. Allie's dad had died when she was little from lung cancer, and she had recently gotten engaged to her high school sweetheart, and their wedding was planned for the following year. I asked, is there anything I can do to make any of this better for you? She wanted her mom at her wedding, and so with the help of the whole team, we made it happen for her. Caring for Mary and her family brought me back to Dr. Wirt's lesson about the importance of helping the families be at peace with their loved one's death. For those of you who aren't familiar with the Three Wishes program developed by Debra Cook at McMaster, it's a program to support patients and families at the end of life. They have a wonderful website with resources and ideas about what the ICU teams can do to make this difficult time meaningful. My next story is about a young woman in her 30s with widely metastatic breast cancer. She had been tried on multiple different treatment regimens and presented to us in respiratory failure. She was placed on BiPAP, and we suspected that her respiratory distress was all due to her cancer. She was young with the fiancé, parents, and siblings at her bedside around the clock. I tried diuresis, which started empiric antibiotics, and I reached out to oncology to see if there were any further treatments or trials available. Then I spoke to her and her family. I explained the situation, and we discussed intubation and what that would mean, especially if there was nothing available to treat her underlying disease. After a few tenuous days with her on BiPAP and ongoing discussions, they decided together that having her die in a ventilator was not what anyone wanted. We had a long discussion about what would happen, what we could do, how we could keep her comfortable and relieve dyspnea and pain, and we also discussed what we could do to make this very limited time they had left meaningful. She loved electronic dance music, so we arranged for that to be playing. They each wanted alone time with her to say their goodbyes, and so we set up a plan for that, and the staff supported them as they went through this process. But this is not the reason I'm telling this story. After she passed away, I went in to offer my condolences, and I took the intern with me, who was new and needed to pronounce her. I spoke with the family. Her mom and I were talking, and I said something about the music, and her mom laughed. I didn't think much of it, but after we left the room, the intern asked me how I got the mom to laugh at such a hard time. I wasn't sure, and I had to reflect, but I think it was possible due to the trust and relationship we had built by hearing their concerns, their dashed hopes, and learning who their daughter, fiance, sister was prior to the illness that took her from them. For us to be able to work in partnership with patients and families, we need to gain their trust. They need to know that we are doing our best to treat their loved ones, and that we will be honest with them when it is time to change course and to focus on comfort. The way to do this is by listening to what they tell us, making time to get to know who they are beyond their critical illness, understanding their values. This is one of the many things that made caring for patients during the COVID pandemic so hard for me. Families were not present in the ICU. They did not see how hard we were working to care for their loved ones. They only heard a voice on the other end of the phone giving them a daily update with no context. It was hard to build trust. I hope some of my stories have conveyed the importance of trust. The dictionary definition of trust is to rely on the truthfulness or accuracy of, to place confidence in, to place in one's care or end trust. And trust is what patients and families do in the ICU. Trust is not only essential to a patient-doctor relationship, but to the functioning of society. Lack of trust can cause chaos to ensue. Trust requires a positive intent, bringing your whole self, respect, and collaboration. I want to turn to the discussion of mentorship. A mentor is someone who imparts wisdom and knowledge. A mentor is someone who sees more talent and ability within you than you see in yourself and helps bring it out of you. I will confess that the English major in me loves mythology, and so I'm sharing with you the story of Mentor. The story of Mentor comes from Homer's Odyssey. Odysseus, who was the king of Ithaca, goes off to fight in the Trojan War and entrusts the care of his household to Mentor. Mentor serves as a teacher and overseer of Odysseus's son, Telemachus. Most people, or many people, know this kind of the background story of Mentor. What most people don't know is that actually Athena, who's the goddess of wisdom, courage, and inspiration, is the one who takes the form of Mentor and actually advises Telemachus. So I've been fortunate to have many wonderful mentors over the course of my career, but I want to mention three of them here. The first is Dr. Lynch Nui, who I met in the very beginning of my internship. I'm sure I think I did something wrong, and she came to correct and tell me what I did, and actually took the time, which she always did, to teach me and make sure I knew how to do things correctly. I mean, so she has been an amazing mentor to me, and I'm sure she'll be I mean, so she has been an amazing career mentor to me since I was an intern. Dr. Sharon Inouye, who is a world-renowned geriatrician and delirium expert, took me under her wing when I was a fellow and has been my research mentor since that time. And Dr. Richard Mathay, who was actually my fellowship program director, was the person who got me involved with the American College of Chest Physicians when I was a trainee. As you have heard, nurses were some of my first teachers, and I've learned and continue to learn from patients and families. I am fortunate to have such good collaborations with our ICU nurses, respiratory therapists, pharmacists, and social workers. As a team, we work to provide outstanding critical care and end-of-life care for our patients. I had the privilege of being the Yale Pulmonary and Critical Care Fellowship Director for over 10 years, and it is great to see so many of my former fellows sitting in the audience, so thank you for your support. Today, I think you've also heard how I've gained insight from trainees. Mentorship is a two-way street, and I learn as much from them as they do from me. Finally, my physician colleagues are a valuable source of wisdom for me. Again, on the left side are some of my co-interns. Again, see how young we all look. And on the right is the Yale faculty who have supported and educated me and made a hard job much easier to do. I want to take a moment to recognize that there are so many women in critical care medicine who are deserving of awards for their research, their research when they are running clinical trials, their research on end-of-life, and especially my mentees, their research on sleep in the ICU and outcomes from ICU care. So we are really fortunate at Yale PCCSM because we have the largest number of female faculty of any division in the country, and so I am very fortunate to be able to stand on the shoulders of all these giants here. I would be remiss if I spoke about end-of-life care and did not address how hard it is to care for dying patients and their families. Today, I have not told you of the conversations that went horribly wrong, the families who screamed at me, who threatened me, for those with whom I could not develop a therapeutic alliance. While it is easy for us to have compassion for our patients, we need to remember to have compassion for ourselves. Kristen Neff does research on self-compassion, and the three components she talks about are self-kindness, the ability to give ourselves some grace, to speak kindly to ourselves when things don't go the way we expect it, the importance of connection and remembering that we share a common humanity, that we all suffer and that we all experience joy, and finally, presence and how mindfulness can help us to avoid two common reactions to suffering, which I believe are relevant to us in the caring for patients, avoidance and over-identification. And I think we've all done that, trying to avoid having those difficult conversations, especially when we're tired and exhausted, and then the the risk of over-identifying with patients, which I think increases our risk as well for burnout. So I really want to encourage you all to be kind to yourselves. So I've told you my stories, and I want to take a moment for, I want you all to take a moment for self-reflection and think about your stories, because I'm sure you all have many stories and have had these same experiences over the course of your career. These stories may make you feel joyful, sad, vulnerable, grateful, angry, but being a doctor and caring for critically ill patients allows you to experience the whole range of human emotion, and how amazing is that? There are many reasons I love taking care of patients, but I will leave you with one. I feel privileged to be able to bear witness. So I want to draw us back to the themes from the beginning of the talk. The words we use and how we say them matter. Whether we want to or not, we all bring our whole selves to caring for our patients. We should take the time to really listen and work on building trust, and we need to pay it forward, mentoring trainees and role modeling for them. Take them with you for the hard conversations, for they need to learn these things, and they are our future. So I want to finish by acknowledging two very important people, Alex and Sarah. They are the ones who got all the artistic talent. They help me keep me grounded and serve as teachers and reminders of what is important in life. It's because of them that I came across Leo Tolstoy's three questions in the form of a children's book. I remind myself of these three questions when I'm struggling. The three questions are, what is the most important time? Who is the most important one? What is the most important thing to do? And the simplified answers from the children's book are, remember, there is only one important time, and that time is now. The most important one is always the one you are with, and the most important thing is to do good for the one that is standing by your side. And so I just need to say one more thank you before I conclude, and I want to thank these four amazing women who are, I've known from all different aspects of my life, who listened to me agonize about what to present during this talk, gave me ideas, feedback, and importantly, love and support. And so with that, I thank you for your attention.

Dr. Margaret Pisani

end-of-life care

effective communication

vulnerability

mentorship

COVID-19 pandemic

compassion