Page 149 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 16: Care of the Caregiver in the ICU and After Critical Illness 115

mechanical ventilation, such as those experienced by Toronto teams
• The specific context of pandemics and natural disasters impose during the SARS outbreak in 2004, or the H1N1virus in Montreal and
a greater burden on critical care staff and require planning and Winnipeg in 2009. Such situations place two specific kinds of pressure
postevent debriefing and caregiver follow-up. on caregivers. The first is related to the sudden increase in the gap
• The stress experienced by trainees exposed to critical care is essen- between demand and the capacity to accommodate critically ill patients.
tial to learning. Reflexive learning and the use of the narrative are Triage of patients to select those most likely to benefit from critical
useful in contexts where emotion and morality are part of the criti- care resources is in direct conflict with the covenant of trust between
cal caregiver’s experience. physicians and their patients. Models of triage, including third-party
decision making, have been developed with the hope of aiding health
care professionals with these difficult choices. The failure of these
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models to predict outcome accurately mirrors the poor performance
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Caring for the sick can strain critical care caregivers. Long working of clinicians in predicting outcome in individual patients, and adds
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hours and sleep deprivation can exhaust even the most energetic physi- to the potentially challenging uncertainty that critical care caregivers
cians. Death is a constant companion to all critical care nurses, trainees, face daily. The second stressor is the risk of exposure to infection dur-
and doctors. Treatments are proffered, and decisions made that alter ing outbreaks such as SARS and H1N1, and the variety of responses
whether patients live or die. Families accompany patients, bringing with among physicians and nurses. Moral and professional obligation should
them their sorrow, anxieties, and conflicts. Teamwork, which is at the apply to all members of an ICU team and to those providing them with
center of caring for the critically ill, can be disturbed by individuals, protective equipment equally. When some workers come in to work and
local culture, and demands exceeding the physical or organizational others do not, and some caregivers are infected with the epidemic virus,
capacities of its members. considerable tension emerges in the postcrisis period. Both of these situ-
Although the stress experienced by critical care nurses has been ations (disasters and pandemics) constitute a small proportion of what
explored in the nursing literature for decades, the first publication critical care caregivers will face in a professional life span, but warrant
addressing stress lived by intensive care unit (ICU) physicians only mentioning because they have all the elements to provoke strain beyond
appeared in 1986. Burnout, a negative consequence of stress, and of that experienced under “normal” circumstances. Whether critical care
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the individual’s response to it, is now understood to affect ICU physi- caregivers are at risk for developing posttraumatic stress disorder or
cians and nurses frequently. Its incidence among physicians is roughly other adaptation difficulties, much like caregivers returning from war
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50% and correlates with overall burnout rates among all (critical care zones, is not clear.
and noncritical care) physicians. This correlation suggests that despite This chapter will focus on two common areas described as challeng-
stressors inherent to critical illness and its technology-focused environ- ing by nurses and physicians alike and which are specific to the critical
ment, the balance between effort and reward may be no different than care setting. These two areas are chosen empirically from a review of
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in other environments. stressors in the critical care literature associated with burnout and care-
The correlation between stressors, burnout, and job dissatisfaction, giver distress, because of their frequent occurrence and relative impor-
and the personnel shortages in critical care should make stress and tance in the context of the critically ill. The first is establishing the level
burnout a policy-driving issue, in addition to a caregiver’s health issue. of care in a critically ill patient—withholding, withdrawing, or limiting
Calls for recognition by professional societies, better organization, and critical care support. The second relates to effective communication.
proactive resolution of stressors within individual intensive care units In ICUs, considerable time and effort are devoted to delivering bad
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have not affected the daily challenges faced by caregivers. No prospec- news, discussing the level of care to be provided to patients, discussing
tive studies have validated the effectiveness of interventions that aim end-of-life (EOL) topics with patients and their close relatives, and
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to minimize ICU physician burnout. Although several studies describe guiding them through the process of deciding to withhold or withdraw
the point prevalence or self-report of burnout symptoms—with the life-support therapy when necessary. 23-25 Senior medical residents often
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limitation that self-reported angst may not correlate with psychological initially decide upon the level of care, medications, and treatment strat-
health —no longitudinal studies of the natural history of burnout over egies for newly admitted patients, and for those who develop further
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time could be found at the time of this writing. Some data suggest that complications during their hospitalization. They spend a great amount
nurses can gain insight into stress and coping with it from educational of time at patients’ bedsides and engage them and their families in
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seminars, but whether this translates into long-term benefit to them, discussions. What trainees considered a meaningful EOL decision-
physician trainees, or other medical staff is not clear. making experience was explored in a recent qualitative study involving
9
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Nurses report futility in aggressive care as an important stressor, critical care fellows. Their experience and the sociocultural context
and conflict and lack of communication as important determinants of within which it occurred were thus considered. Negative experiences
professional well-being. Physicians, on the other hand, are more affected accounted for the majority (58%) of stories, followed by negative experi-
by workload, conflict and communication issues with peers, but not ences with positive learning opportunities (37%), while only 5% of the
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by communication with nurses. Caregiver gender, resilience, and descriptions were positive. Descriptions of suffering were ubiquitous,
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personality probably play a role in handling work-related challenges and paralleled the perception of suffering in ICU patients. All inter-
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and developing burnout as well. A healthy work climate can improve viewees considered revisiting their difficult experiences as valuable. All
personnel retention and professional satisfaction in all team members. expressed gratitude at the opportunity to tell their tale. A wide range of
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Effective multidisciplinary teams are associated with lower patient emotions was expressed by the participants.
mortality. Conversely, and in the context of the medical crises that Although some publications address the burden and distress of health
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characterize critical care, entire team performances and perceptions can care providers in ICUs, 28,29 medical culture does not easily acknowl-
be affected by one or more individuals. A healthy professional envi- edge caregivers’ suffering as part of the EOL experience. Insistence
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ronment thus seems a sensible goal from every perspective. Strategic that professionalism involves removing oneself from emotions refutes
implementation of communication strategies around end-of-life issues the dimension of caregiver suffering, and does not acknowledge the
minimize conflict and appear to improve burnout rates. Once burnout important impact emotions may have on day-to-day team interactions,
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occurs, no intervention has unequivocally been shown to be effective. 18 learning, and professionalism. Most descriptive accounts of the deci-
Additional tension can be placed upon entire health care delivery sion-making process for physicians do not incorporate emotions into
systems in situations of natural disaster, such as those experienced by the paradigm. Deep emotional experiences, however, can be harnessed.
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caregivers during Hurricane Katrina in New Orleans in 2005, or dur- They are associated with retention of information and can trigger a
ing outbreaks of infectious diseases during which more patients require reflection process that shapes learning experiences. 30
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