Yeah, I'm Susan, and that picture is my trio of kids from the last time we were in Hawaii, January 2022, my first trip post-COVID. I sing in a choir as part of my self-care, and I really wish I had learned some of the skills we're going to talk about today. When I was in training, I learned from colleagues along the way, and hopefully we can pass along some of those great skills to everyone here. Good morning. My name is Esteban. It's a pleasure to be here with you today. I am a full-time clinician, critical care, and I'm also an executive coach from Georgetown University, and I am very interested in wellness and moral injury in the healthcare profession. Thank you, everyone, for coming in this early to see us. I really appreciate it. Thank you, Carlos, for putting this together and for everyone. My name is Diego Maselli. I work in San Antonio, and I've been there for 10 years. I do a lot of ICU and pulmonary, and it's a pleasure being with everyone today. Looking forward to the discussion. Thank you. I'm Carlos O'Brien. I'm a person who has a lot of time and experience in our hospital and clinic, and what we're just starting to do in our institution is to support our patients' regular healthcare experience. Every time we start doing this, Carlos and I, we think it's a hard call to answer. I don't think we're going to be sure. Our goal today is to provide some tools that will allow us to better contribute to ICP recovery and other issues. The idea is to divide it into four parts. There are only a limited amount of people who are interested in our work, and we're going to discuss the cases that we're going to present. You can select one of the first three or four persons, but anybody can be part of it. The folks who are going to be the better suited to each of us are going to be this topic, and we're going to discuss two cases. The first case is going to be the one that we're going to spend the most time on. The second case is going to be the shorter one. And as you can see, we're really going to put together the most of the topic. We're going to have an active discussion, conversations, questions. And these are the problems. This is a safe space. Okay? We're going to be doing things that are going to be here. We're going to be doing things that are going to be used and going to be shared. We're going to be presenting what we're going to have. We're going to be coming to you. I'm so close. Everybody's listening. It's big, and that means a lot to the American public, not personally. So this is one of the first three or four questions. The next case is going to be the half. We're going to go ahead and in your eyes, you will be in three different positions. After, it's time to take the laptop. You don't necessarily have to be holding it. You don't necessarily have to be part of the laptop. Okay? This is the way things work. Somebody is going, and you're going to take the desk. Okay. Okay. So we're at it. And 56% of the time, it's called 20% or at least 80%. So we're expecting there is a question. I'm going to bring it into session at 1 o'clock. And people are allowed to express their opinion or that you are providing space. Here is the last one. Let's see. So 50% are going to be aware of it. So even when we do it in those systems, other cases, it might be independent. And do you feel that your ICU creates an emotional safe and supportive environment to discuss these issues after an adverse or challenging case? Kind of neutral responses, maybe some agree. OK. Now, so let's talk about some of the important definitions that are going to be key for these exercises today. So a lot of these definitions will be familiar to people, or some of them will be. But just so we're all on the same page and really starting from an equal footing and starting place, Esteban used the term moral injury. And moral injury and moral distress is really, I think, at the core of what we're talking about today. It's this perpetration or failing to prevent, feeling like you're perpetrating or failing to prevent, or bearing witness, which every one of us in this room does, to, or learning about, acts that transgress our own feelings of moral footing, moral beliefs and expectations. In other words, it's kind of like feeling like you know what the right thing to do is, but not being able to do it. So this is often the definition many nurses will use. They feel like they are giving care to people, that they feel like they're harming them, or they're inflicting suffering, or worsening suffering. And I think all of us in health care have felt this at one point or another. Burnout is a term that goes around all the time. It is really kind of defined by the feelings of exhaustion, emotional exhaustion, physical exhaustion, in the settings of prolonged stress, frustration, in the workplace, and is often highlighted by cynicism, poor performance, lower mood, and distancing, almost removing yourself emotionally from a situation. So you might be coming to work, but you might not really be present. Vicarious and secondary trauma are terms that are used to kind of identify the fact that even though the trauma isn't happening to us, it's happening to a patient and their family, but we're experiencing it as well. And so it does cause some trauma responses in us as well. And I thought it was really important to put the term grief here. So one of our favorite quotes in palliative care, might be familiar to one of you in the audience, is that if you think you can do this work and not grieve, it's like thinking you can walk through water and not get wet. And that's Rachel Naomi Remen. And I think it really highlights the fact that we have to acknowledge that we are grieving. Futility, very challenging definition. In New York State, the definition that I was taught when I was in training was it would be trying to do a resuscitation event on someone who was decapitated in a trauma. So that was like the extreme futility definition. But it is a little bit ethically controversial, and we'll talk a little bit more about it later, but it's really when the proposed treatment will not work, so maybe you have evidence it won't work because you've tried it and it didn't work for the outcome that you had hoped or intended. It may mean it gets tricky because some people think about quality of life versus quantity of life, and we'll get into that a little bit later. Anchoring bias, just as a baseline, favoring the initial impression one has, and then not being able to kind of move from that when new data comes. And we've seen this happen in the ICU a lot. People kind of go to one conclusion and then they kind of can't get out of that. And we thought it was important to include the last two definitions. Maybe familiar to some, but not everyone. And the concept of countertransference is something that we see all the time in the ICU and in the hospital, but if you're not aware of it and don't know about it, you won't know to look for it. And that's the idea that we unconsciously redirect certain feelings or emotions or expectations toward patients based on our own experience and relationships with others. And this can really impact our decision making. The classic example, that patient reminds you of your beloved grandfather, and you're really having more emotional difficulty with the case because of it, or seeing it objectively. And then lastly, we all decided it was important to include hope here. That word gets thrown around a lot. It is really a feeling of expectation or desire for a certain thing to happen. And we of course always hope along with our patients and families, but we also don't wanna give false hope. And so that plays into some of these challenging end of life decisions. So we're gonna have this case that we'll discuss and we're gonna break into the groups that we mentioned. So we'll go through some of the potential challenges and discussions. Let's think about, you just, part of the ICU team, routine day, you're rounding, you have a young woman who had been admitted with sepsis and got complicated with sepsis-induced cardiomyopathy. She now has mixed shock, cardiogenic and septic, multisystem organ dysfunction, worsening renal function. And you round on her, you're about to move to the next patient, she sustains a PA arrest. She resuscitated for 32 minutes, but despite the efforts, she passed away. She is pronounced dead and there is a minute of silence. Then there is the briefing. Talk about how the code went, the activation of the code, the doses of epinephrine, did we identify the rhythm, how was the quality of the CPR? Review of the protocols and the standards. Then you continue, after the briefing, to go to the next patient, but the senior resident stays behind and starts to cry. And then two more team members seem concerned. One of them is angrily saying that we should have called an ECMO consult in the morning. And then the nurse just say, what's the point? She whispers, you know, quietly, everybody dies here. So what emotions are we identifying here? Who wants to start? Maybe we can probably name one of the emotions that we're seeing in these patients, in these RA providers. Grief. Grief, apathy, okay. Anger. Hopelessness. Moral distress. Regret. Very important. Anything else? Sadness and despair. So we hear different feelings and we also hear some more defined concepts as Susan was discussing. So a couple of questions before we move into the exercise. So we set the ground as well. So, and we understand who are our colleagues here today? How are we learning from each other? So when this happens, how comfortable you are talking to a colleague or team member in the ICU who needs emotional support for anything that was related to patient care? Let's say, again, a cardiac arrest and death, an adverse event, a potential medical error. Picture yourself seeing that trainee crying. You're making eye contact with that scene. She's crying, she or he. We didn't say the gender. Is that person is crying. How comfortable do you feel handling that emotion? Okay. This is very encouraging. This is very encouraging. That's what we see. We're gonna be learning a lot from you guys. I'm very curious. Can I ask one, someone who has answered either comfortable or extremely comfortable, how would you address that person? So what would you say to that person? That statement, you would say, it was a sad case. You name and acknowledge that. I think that's very important. That's great. I would ask her a question. I would say, tell me more about what you feel. Tell me more about what you feel. I like that. Instead of asking a question, Esteban uses a sentence. What, before I go to the sentence, the one message that we want to send today is it is very tempting to ask the question, are you okay? And it's probably not the best answer, the best question to ask in that particular moment. But let's say that you said, are you okay? And that person cannot come to words. He or she are just having a very hard time for that. One way that you could approach that person would be, if those tears have words, what would they be saying right now? And that person probably is going to connect a little bit deeper and express whatever is going on there. Great. I love this. It's coming along very nicely. Now, in your own institution or ICU, are there any systems or programs in place that help support team members in situations like this, requiring emotional support? Okay, let's take one. Did you get it? I will have the full survey at the end, too, if you want to take it. But, so, I think that's it. Thank you. So, I'm interested in spread. It sounds that some programs, some institutions have their programs, okay? Yeah? Half of them? Now, if there are such programs in place, have you ever used them? So, we are asking you, yes. You, in particular, have you ever picked up the phone and dialed an 1-800-EAP number or whatever way of support you have in your institution? Or maybe go to the yoga class at 1 p.m. or 2 p.m. when we are all doing procedures in the ICUs and having family meetings. Or maybe you take your day off to come back to the hospital to take the yoga class. Yeah. And this is kind of what we expected, because I think there are several layers to this, and we'll get into this a little bit deeper in a few. Now, since, again, we were hoping to divide into four, but maybe we can have two teams, this side and this side. You guys are welcome to join us, but I want you guys to talk a little bit amongst yourselves to answer this question. So, let's say you two are going to choose, this side is going to choose the first two questions. Describe what is behind the emotional response. So, we hear some words about emotions, but there were other things that were already elaborated, like moral injury. So, what are those feelings that the team members are expressing? What is underneath those? And then the second question will be, what are your specific challenges in your ICUs? And we have different folks here, probably from different backgrounds. So, what are you seeing? Is it about the time constraints? Is it about the comfort level? Is it about the atmosphere of the whole unit? Or any other issues that are related to this? For you guys, what will you guys do in real life? What do you really do? As Stephen said, maybe we tend to ask the question, are you okay? And what do you think we should do to handle the situation better? So, maybe let's break for five minutes and talk, and we're going to be walking around also to kind of facilitate the discussion. We were hoping to have the roundtable set up, but it didn't work. We might have enough people in the back two sections now to have them each be a group. So, why don't we, you know, there's a few people there. Yeah. A few people there. So, we want to do A here. The first question is this group. B is that small group back there. C is this larger group, and you can kind of form into two groups and get near each other. And then D is the group in the back. And I just want to clarify, unmet needs in your ICU is specifically about emotional debriefing and emotional care of our teams. Yes. Yeah, don't tell me that we need three gyroscopes and more vans and, you know. That could probably not help with that. So, A, B. C, D. Okay. Just think about that. Think a little bit about what you do in real life and what you think you should do. Because, again, we always have this, but in what elements you have. Because I think we all have different backgrounds and we have different trainings and different ways to handle things. So, try to provide your recommendations. We have one more minute, one more minute for the discussion. And if each group can identify one person who can maybe just give a talk out of some of the main concepts that came up in your answers. Okay, let's, we're loving that this is, there's so much conversation and we also recognize some self-selection in this group based on the survey. Before we go on, just a show of hands, anybody here trained in palliative care? One, oh wow, one, two, three, four, five. Okay, so that's a really large percentage, which explains some of our answers. We're so happy you're here. I'm particularly happy you're here. I am happy too, because I call them all the time. Okay, so who wants to start? Anybody wants to start or should we just start in order? Okay, why don't you guys tell us. Yes, please. So I'm representing, I'm Jenny, I'm representing group C and we were talking about what do we do in this real life, in real life. And a lot of really good content. First, it was naming the emotion, it's being self-aware of what's happening. Then also validating, you know, what people are feeling and taking a pause. But then beyond validating, you know, as you're processing, what have we learned in this situation, you know, and what steps forward. But we also recognize that there's lots of time pressures to do these things in a really busy ICU setting. So kind of the struggle becomes when does this, when can you fit this in, you know, if you've got other sick patients and you're rounding and all of the things. But really great conversation. Perfect, thank you. You guys want to continue or? Group A, shy group A. If you want to sit in, we can, it's easier too. So, so do we think it's burnout and emotion? I don't know that emotion, I think it just plays into the stuff. Right. And then you have a very, very emotional case where that begins to spill over a little bit, and then all of that tends to come out. It's not necessarily what affects this particular case in the beginning, but it comes out at the end because it has all that pent-up emotion. Exactly, and whatever those three team members are bringing from home as well, what's happening in their own personal life, that one of them is crying, one of them is angry, and the other one is just disconnected. Yeah, I guess to point out that sad, angry, frustrated are the emotions, and grieving or burnout are sort of like these processes that are underlying some of the emotional content that you're seeing. In my head, it's kind of nice to think about them as like, okay, this is the emotion I see, but what's behind it? Is this grief? Is this burnout? Is this some other concept that's playing out, showing us these emotions? And it's also important to not only look at our colleagues in that, but when we also are going through something and the way it's coming out to the rest, we might not be aware of what we're demonstrating at that particular moment. And that's why it's so key to kind of transform that or understand the process from the process underneath to what is coming out to the surface. Attention here. We have used the word grief. Grief is normal. We all grieve. And I want to ask each one of you, do you allow yourself to grieve? Do we allow our teams to grief? Or do we see grief as an abnormality? She's too sad. She's crying. She's not functional. She needs time off. Grief is normal. Yeah, I think that's key. And our question is also the time and the place, right? Because, again, the rapid pace units that we discussed, but go back to the specific team. And then the team who went through that event that day, if it was a specific event, might not be back the following day when you're planning to do it. So it's also that complex part to it. And one comment. I love that you brought up chaplaincy. They're actually trained to do this. This is actually part of their job. And we underutilize them in most spaces. I think the palliative care folks know how to use chaplaincy a little bit more than maybe other hospital professionals. But this is why they're there. And they actually are trained in doing this. So utilize them well. What about you guys? Well, we put you in group C, but group D is much bigger. No worries. So in terms of best handling, it's really a lot of allowing space on with whatever emotions they're feeling. I love that because you kind of connect with that person at a more, you know, close level. So I think that's very important. Okay. Any other comments or questions anybody wants to bring up? I would like to follow up on that particular comment. It is extremely helpful for both the asker and the person that is being asked a question to ask specific questions. We all humans have the need to be seen and to be heard. And that person that has emotions and is probably struggling to express the emotions just need one question. How did the death of this person is making you feel? How are you coping with the death of John? So as opposed to are you okay? It was not a coincidence that this person that is in distress in this case is a trainee. Because what you pointed is absolutely right. The nurses may have a union. The nurses have a hospital employee has all this kind of assistance. What is the trainee feeling? I was not enough. I'm not good at this. My life sucks. You know, whatever storm of thoughts are going on. You can argue sometimes even that the trainees have a program director depending on how good the program director can be. But what about us at the attendant level or the APP level? The advanced practice providers are also in a vulnerable spot as well. I think you're right. What you are trying to say like this is like the alarm of the patient of the vital signs or the pH getting worse, the oxygen not picking up. This person needs an intervention. I think it's important to understand that in the flow of the day. Don't stop there. But you have to acknowledge that. I think that was a very important point. Plus I want to add about the trainee is they're learning skills now. They're learning how to do a code. They're learning how to put in a line. If we don't also train them in the core clinical competency of being self-aware of what's happening in here emotionally and what to do about it, then they will become the rest of us who didn't get it in their training. So we want to make sure that it's part of their training. And so making space for it, modeling it is going to be part of that training. So I love that you said that's the most important person right now. And you're right. If we can spend an hour on a code, we can spend ten minutes with an emotional supportive debrief. In the ICU, we build up these teams together, and we know each other for many years. But the trainees, some of them are the first day or the first week. And there's so many faces, so many teams that you don't know who is who. But it's still a very hard time. So you go to war sometimes, and then you don't know who's the person that's helping you do the compressions. You just met them that day. So that's why it's a little bit difficult to disconnect. I think we have to say, well, this is a new person. It's a new environment. Just like you said, a little bit of a higher risk than the person that has more experience. Particularly at the senior level, you can see, oh, this person is definitely encountering a new experience. So I think that's something that we have to take into consideration. So let's move. Let's talk about the report out and some of the things that we just reviewed. We're kind of like really trying to support our teams. Understanding all these processes that are happening and what is underneath. So we just wanted to include a slide or two about how do all of these concepts, moral injury, grief, burnout, play out in the ICU when we're dealing especially with end-of-life situations. The first bullet is what I like to say is people going to the end of the story. You know, every one of the people in the ICU could die. Actually, every one of us in this room will die. And so going to the end of the story is what I say when people are sort of jumping ahead and they're not realizing that the person right now is alive. And they start talking about the person as if the ending is tomorrow or today when just because someone has a terminal illness doesn't mean they're dying right now. And the family is hoping that they're not dying right now. So I think that's one of the errors that I see and one of the problems that I see when I'm consulted is people are going straight to the end of the story and they're not right now. We often also get called when there's failure to reassess, when there's improvement or deterioration. So that gets a little bit to the anchoring bias we talked about earlier is you kind of come in, you've kind of made an assessment on day one, but then the patient actually starts to get better. We see this in palliative care when we get called for a palliative extubation and actually when we go assess the patient and talk to the team, it sounds like they're on the border of a medical extubation versus a palliative extubation and the family is still hopeful. And maybe they kind of, in their heads, they're thinking palliative extubation and then the patient is alive four days later, but someone's knee-jerk reaction started a morphine drip on this patient. And so we haven't really reassessed where the patient really is. There's also failure to recognize our own, we talked about it, the counter-transference or our own unconscious reactions to a situation, and often we fail to recognize or address the moral injury in ourselves or our colleagues naming it. This is my reminder to say I teach my trainees that sometimes 50% of the ICU consults we get, we get called for goals of care, but what it actually should say is we're calling you for moral distress because there's conflict or challenges. And I try to teach our fellows in palliative care early on to recognize that, okay, the goals are so clear. The consult is more because the team is distressed about what the goals are. And us going in there and hitting someone over the head to change their goals isn't how we operate, but if we also don't address the moral distress that's going along with the goals that the family has, then we haven't done our job. So the consult order says we're calling you for moral distress, but we're thinking of adding it to ours, but it's our job to recognize that in ourselves. And then also I think as a program director teaching trainees, I think it's so critically important that we are modeling and teaching these competencies, as I mentioned before, because if we don't, we're going to create another generation of providers that don't know how to manage these situations. So how can we mitigate the negative impacts of moral distress and other emotions and concepts that we've talked about? Reflective practice is a general term, and we're going to talk more about debriefings later, but I think reflective practice can happen at the individual level. What am I feeling? Writing, journaling, narrative medicine. It can happen at a team level. The debriefings that you guys share that you do on your team when someone is having an emotional reaction. It can be system and societal ways as well. I put the system in societal ways here because I think early in the self-care language, we kind of put it all on the self and the person. This is not a problem that we have. This is a problem that the system has created. Yes, there are things we can do individually to mitigate it, but we can't put the blame and the pressure on each of us as individuals. We have to change the way things are happening in order to also help. Wellness, resilience, self-care, these are all words you hear going around in palliative care. It's always been a core clinical competency, and I think now all training programs are getting the realization that we need to train everybody in this. Education, education, education. I also am a firm believer in when you're having a case like this that's challenging, whether it's challenging because there's conflict, like the family wants something and the team doesn't think it's reasonable, or whether there's conflict on the team, someone thinks you should do X and someone else thinks you should do Y. But multiple perspectives on morally challenging cases is helpful. Multiple disciplines. You mentioned spiritual care, social work, nursing, physicians. That's how a palliative care team runs, but I think that multiple disciplines input can really help people sort of move forward in a case like this. We're going to move towards how to conduct debriefings, and we're going to go through one very important topic. We have spent a lot of time in critical care, hours learning about mechanical ventilation, about interpretation of Swan Gans catheters, about shock in all the different flavors and presentations. But how many of us spend any time or training on how to feel and how to deal with emotions? And that's what we're going to talk about in the next couple of minutes. So some pearls about debriefings. If you don't have a structure in your ICU for debriefings, do that first. Do not jump into a debriefing without structure. A debriefing without structure is more harmful than helpful. So that's the first step. If you work in an ICU that does not have a structure for debriefing, start there. And there are many tools, and we will be more than happy to provide those tools if you need help with those. Number two, during a debriefing, we need to level the field. What does that mean? I'll tell you this with an example from two weeks ago. We have a very unexpected death in our ICU from a very young man who was very important in the community of Washington, D.C., and that was catastrophic for the team. It was unexpected, and during the resuscitation, one of the nurses did not see change of color in the colorimetric capnography, and she was questioning if the endotracheal tube was in the trachea or not. So this became a great opportunity, an educational opportunity. When she verbalized that, we were able to tell her, during cardiac arrest, it is not expected to see that change in color. So that immediately took away from her the burden of, was that tube in the trachea? The third point is what we have been talking during the presentation, is the emotional support. How do we address emotions during a debriefing? In general, debriefings go through a general clinical summary, what went well, what didn't go that well, what did we learn, how do we move forward? But the reality is that we are emotional beings, and the amygdala is hijacking us during those moments, and we must address emotions. And one way to address emotions is to ask, what are the emotions that are present in the room? I can see that there is distress, or I can see that there is an energy in the room. Can someone talk about this? And open the window for the emotions to come out. If we don't open the window for those emotions, that person and the team could be trapped in rumination of the emotions until they get addressed. This is one of the ways how burnout develops. Because if the team is thinking, this was ridiculous, this code went for way too long, I was sad, I was angered, da-da-da-da-da-da-da-da-da-da-da, if those emotions don't get addressed, this is just going to perpetuate that cycle. Then the identification of errors or near-miss, and then understand that debriefing, both clinical and emotional, is a very powerful tool for burnout mitigation. However, we know that we don't work in an ideal place and in an ideal environment. Many places lack structure, as we have said. I want to echo the comment that was made a little bit earlier, where not all the systems are mature enough to handle this. You may have mature people, but the system may not have this maturity in place. Lack of time and space. The code just happened. The care for the other 10 patients, or whatever the number of your ICU is, has been delayed for those 20 minutes or 30 minutes that you were running the code. Now you're asking the team that is behind to sit down in a room and have a few minutes of conversation. That has to happen, but let's be realistic. We are going to be having a pre-volvulus sensation with the alarms that are going on and with the care that has been delayed. We need to be also concerned about the emotional impact and re-victimization of some members of the team. Since talking and addressing emotions is not that common, it is very likely that one or two or more of the members of the team are going to be reliving a traumatic experience with what just happened. There comes the comment of, you see, what's the point? They all die. Why do we even do this? Learn hopelessness. Hopefully, one thing that we will stay away from doing is because it's the easiest thing to do, is to say, here is the 1-800-EAP number. See ya. Good luck. That is, yes, the 1-800 number is there, but it is your team, your responsibility, your ownership. After debriefing, if you recognize that there were emotions present, it will be very helpful to have a follow-up. One week, a few days. What are the challenges of the follow-up? You are very unlikely to get that very same team together. But please, please recognize those two or three people that were very emotionally heavy. Follow up with them. It's been a week after John died. How are you doing? Be specific. What strategies have you found that are helping you in the last week? How are you sleeping? Are you eating okay? How was coming back to work? Be that specific. What is the question that we are not going to ask? Are you okay? Yes. Let's steer away from, are you okay? Because that's like the manager doing a walk in a restaurant. Everything okay with the meal? What's the only answer that he's going to get? Yeah, thank you. Move on. After you have been complaining about the meal for 15 minutes. And then confidentiality, confidentiality, confidentiality. Whatever is said in a debriefing should not be, unless you are going to help the system replicating the comment, it doesn't help anybody else to perpetuate the comments that came out during a debriefing. Now, the part where we learn how to feel. We have three ways to deal with feelings. The most common one, resist them. I'm angry. And then you start denying it. I'm a happy person. Everything is okay. I will move on. The second one, buffer them. Drinking, overeating, overspending, over social medializing, if that's even a verb. But then there is a third alternative. Feel the feeling. Feel the feeling. How do we feel the feeling? Well, I want you to think about a feeling like a ball, a plastic ball in a pool. When the plastic ball is floating in the pool, you don't even think about it. But when we start resisting the ball, the more resistance that we put to the ball, the easier that ball is going to hit us in the face. To avoid that resistance, we create a space. Debriefing is a space. You create a time to name the emotion. We were very pleased to see that with the first case, you were very able to name the emotions. You will be very surprised how many times in healthcare we ask the question, what is the emotion? And people are unable to name the emotion. Label the emotion. Describe it in detail for yourself. I'm feeling angry. And when I'm angry, I feel this pressure in my epigastrium that I feel that my bowels are twisting. That's anger for me. Or anxiety. Or I feel my hair in the arms getting a little bit sensitive and I have this cold sweat running out of my spine and I feel palpitations. Ah, okay, that's anxiety. Okay, yeah, I can feel that. I can deal with that. It's not as bad as my mind is making me think that it is. So those are some recommendations on how to deal with emotions and how to feel. Thank you, Sam. That was great. I think in the interest of time, we might go through this case very quickly. We have a couple of minutes and just to be cognizant of the next session. Now, think about this other scenario. You just took over service, and this is a young patient who came with appendectomy and got complicated with a viral pneumonia, got intubated and it's been right with ARDS, high vent settings, it's not getting better, worsening gas exchange, hypotensive, the RV is now in trouble, and you call a multidisciplinary team discussion. His BMI is 38. The team comes to the bedside and they're all arguing, the transplant team, the ECMO team. The previous attending comes and says that, you know, he just took over today, so he was here until yesterday on service, but he came his days off to tell you you've got to help this patient. I know the family, they want everything. Somebody says it's more than ECMO, it's just more than VV, maybe he needs VA. All these things are coming into this place and we wonder if this could be futility. By show of hands, who thinks there could be a futility scenario we put this patient on ECMO to try to get him through his... Anybody would put this patient on ECMO? No? Everybody thinks this would be futile to do ECMO? No? Okay. Well, as I mentioned before, futility is an overused term, and I think we... It's not fair to discuss the word futility in three minutes that we have left, but it's something that we commonly see as a concept for palliative care when it's misplaced, mislabeled, when it's really more than maybe moral distress behind and trying to understand what's happening with our own values and the patient's value. Some of the recommendations to think about a potentially inappropriate or non-beneficial treatment in a framework that we wanted to bring here is think about what are the specific goals for that patient specifically. Is this something that we're trying to prolong life? Work on quality of life? Can we cure a particular condition? If those goals can be reached or not, you can assess if there's a specific therapy that we want to try. It makes sense or not. If there is a role, keep reassessing. Try it. Do the trial and see. If it doesn't, start thinking about any way that we have to readdress the goal. Curative therapies are not appropriate because that's not the goal anymore, but we can focus on comfort or quality of life. Are we having issues with those specific goals? Are we having issues or any barriers that we need to address? And while we do all this, ask yourself if you're supporting the family and your team in the right way. With a framework, two things that can be very useful. One is start the conversations early. Continuous updates and clear communication. Continually reassess what's happening because it's a dynamic situation. And as we mentioned two or three times already today, seek support. Data demonstrates that early consultation for palliative care, making a pitch for my colleagues, really improves team dynamics. I just want to mention, Esteban was talking about the amygdala, so that family has an amygdala too. So if we're not addressing their emotions, we're not going to be able to move forward with shifting goals. So I think, unfortunately, we have to close today. I want to leave with this quote here. It's very appropriate for Hawaii. The whole Hawaii grief, Israel came back to go well when he died. And as he said, there is still something to look forward to. And if you guys want to take a last shot at the survey for today and reach out to discuss quotation, collaboration for this topic, thank you so much for coming today. This was a very key session for us to really understand where we are and really start addressing an issue that is important for clinical care providers. Thank you. applause music

healthcare professionals

emotional challenges

support

futility

debriefings

reflective practice

conversations

holistic approach