Rae Woods: From Advisory Board, we are bringing you a Radio Advisory. My name is Rachel Woods. You can call me Rae. Rae Woods: Over the last 18 months, we've spent a lot of time talking about the clinical workforce, but if I think back to the beginning, we were talking about nurses and doctors as heroes, and we're not really having that conversation today. This moment feels very different. Amid the Delta surge, clinicians are having to make difficult, maybe even unethical decisions when resources are running thin. Rae Woods: I wanted to bring somebody to the podcast to talk about those decisions, the role that leaders and administrators play in protecting frontline clinicians from those decisions and what it ultimately means for the people delivering care. To do that I brought Dr. Cynda Rushton. She's a Hastings Center Fellow and a Professor of Clinical Ethics at the Johns Hopkins Berman Institute of Bioethics and the School of Nursing. She is a big deal in the ethics field. Rae Woods: Hey Cynda, welcome to Radio Advisory. Dr. Cynda Rushton: Good morning. Great to be with you. Rae Woods: You and I aren't technically that far apart from each other, but of course in the pandemic, I think it feels like we might as well be on other sides of the country. You are in the Baltimore area, right? Dr. Cynda Rushton: That's right. Rae Woods: Well, I will be waving to you from my side of the river over here in Alexandria, Virginia. Dr. Cynda Rushton: Wonderful. Rae Woods: Cynda, I wonder if you can start by just describing the moment that we are in. I keep hearing terms thrown around like crisis standards of care or care rationing. Level set with me; what do those things mean when we see clinical, I might call them ethical dilemmas cropping up? Dr. Cynda Rushton: Well, we do have kind of an alphabet soup of terms right now. The terminology of crisis standards of care is really meant to signal the extreme lack of resources that are present in our healthcare system in response to the number of people who actually need care. We have talked about this for the entire pandemic, but it's becoming a reality in a way that it has not before. What that means is is that there's more people in our emergency rooms, in our intensive care units, in our hospitals, in our communities who need healthcare and we honestly don't have the people or the resources to actually deliver what we would under normal circumstances. Rae Woods: I wonder if you can give me an example or maybe share a story that exemplifies this moment of how not having enough resources ends up affecting the real people that either need to make decisions or need to carry out decisions for care delivery. How is this manifesting, especially amid the Delta surge that we have today? Dr. Cynda Rushton: You could imagine yourself being a nurse in an emergency room where the ambulances are coming in moment by moment, the people in the queue for registration are out onto the pavement, and you're trying to figure out how are we going to take care of all these people, when you just heard there's no more ICU beds, there's no more nurses who are able to provide care, there's no buffer, and you're confronted with yet another person in front of you who clearly needs treatment. They're having trouble breathing. They're really decompensating in one way or another. And you're faced with, we have to make a hard choice here. We work in teams, we try to work together to find those solutions, but often those kinds of hard choices were kind of episodic, and now they're chronic. It's every day, every minute is having to make a hard choice. The choices all have consequences that are largely unacceptable to us. Rae Woods: We'll dive deeper into this impact on the workforce itself, but with that kind of context in mind, I want to actually take some time to talk about what this means for the system of care delivery more broadly. My understanding is that true crisis standards of care and something called contingency standards of care are a little bit different. In either of these worlds, how are decisions actually made? Who makes these decisions? Dr. Cynda Rushton: In the space of what we have called contingency standards of care is where we've lived for most of the COVID pandemic. It's a place ... there's intense constraints on our resources and people who have endless needs. The way we typically respond to that is we try to ask the people who were there to do more. We try to change the delivery priorities in terms of things like elective surgery. If you need your knee replaced, you're probably going to be delayed in getting that surgery done. We try to transfer patients to other facilities or to other levels of care. But when we reached crisis standards of care, all of those mechanisms that we've tried to be able to reallocate, to delay, to intensify resources in certain areas is not working. It's a very high threshold of scarcity to decide that we are in crisis standards of care. Rae Woods: Who makes that decision? Dr. Cynda Rushton: One of the features of crisis standards of care is that they require a governor, a state official, a leader to declare for our state we have met that threshold of scarcity, and we are going to make a formal declaration, which goes along with some legal and regulatory protections for the people who are providing care. One of the challenges is that we've seen in this pandemic is our threshold for invoking those protections is so high that by the time we get there, we really have exhausted all of our potential resources, including the people who are trying to provide care. Rae Woods: It, of course, doesn't mean that the people trying to provide care haven't been forced to make difficult decisions for a very long time, but to your point, they don't get any of the protection of this true declaration. Dr. Cynda Rushton: Exactly. So what's happened is by not declaring the crisis standards of care, essentially they have transferred the burden of making those decisions onto the individuals who are confronting patients moment by moment, because one of the features of crisis standards of care is we typically engage triage teams, and those triage teams then are in a way a buffer for the frontline providers to not bear that burden of decision-making. So there's this triage team that is separate from the actual people providing care, who can make those decisions. That relieves the individual who has a person in front of them clearly needing care to not have to choose themselves. Rae Woods: That's such an important feature of these triage teams; protecting the frontline clinician while also trying to help the enterprise make the right decisions about how to deal with scarce resources, which is exactly where I want to go next. Do you have any recommendations for these teams for how to make decisions that are both high stakes, but also equitable? Dr. Cynda Rushton: Well, that's a really important question. Rae Woods: Simple, right? Easy to answer. Dr. Cynda Rushton: I had the opportunity to be a part of a team here at Hopkins and also in our state trying to create those algorithms, if you will, those processes, those allocation guidelines throughout the pandemic, and they're not easy to do, but there is a growing sense that those algorithms have to be done in a fair and equitable way. What we've learned is that some of our systems of looking at how sick a person is have embedded in them some biases. What we've been learning is that we have to really think about how scoring systems and other ways of looking at a person's illness may in fact cause inequities. Dr. Cynda Rushton: So having an algorithm that alerts us to pay attention to that, and to try to look at each person in a standardized way to diminish the possibility that our biases may be operating in ways we're not even aware of is part of that process. That's why it's important to have a team of people who are looking at the exact same information, and everybody's looking at it a little bit differently, but hopefully through that group process we have a better opportunity to reduce some of those inequities. Rae Woods: Any advice for these triaged teams? Dr. Cynda Rushton: So having been part of developing these elaborate algorithms, I think we missed an important element in them. Instead of focusing on how we're going to allocate ventilators and blood and medicines, no one wanted to talk about how we were going to allocate our people. I think that we need to invest the same amount of time and attention and discernment to figure out how are we going to allocate our scarce human resources. Rae Woods: The million dollar question here though, is where does the role of vaccine status play, because that can be a bias that somebody might feel in the moment, but it also seems to be a relevant piece of clinical information when making decisions? Dr. Cynda Rushton: There's a lot of argument about what the role vaccine status should have in these allocation decisions. I'm not aware of that criteria being part of any crisis standards of care allocation algorithms at this point. I think there's a lot of judgment that goes along with using that criteria that could lead us to decisions that may result in unfair inequities. Rae Woods: To your point, this comes back to the crisis standards of care decisions, that doesn't mean that individual hospitals aren't making other decisions around how to think about delivering care based on vaccination status. There's been a lot of talk lately. There was a Washington Post article about an organization that was taking patients off of the transplant list if they did not have a COVID-19 vaccine. It got a lot of negative commentary. But then when you peel back the layers, you think, well, that's a pretty standard way to think about who might get a transplant, especially since you're going to be immunocompromised following that procedure and so on and so forth, but what you're saying is that tends to be separate from crisis standards of care decisions. Dr. Cynda Rushton: What we strive for in creating these allocation frameworks is how do we reduce the likelihood of bias? How do we actually apply them in a standardized way so that it's trustworthy and transparent and people, for example, with disabilities are worried that they may not be given the same opportunities as other people? That's really been a challenge. The reality is none of our algorithms are perfect. There are all involved trade-offs of different types, but the purpose is to try to orient us toward doing this allocation in a way that actually is respectful, that is transparent, that addresses the potential inequities and try to calibrate those as best we can. Rae Woods: This is exactly why we need to remove individual clinicians from the decision-making process, but it also doesn't mean that those clinicians aren't going to be impacted at the end of the day by the decisions that they are carrying out. What does this mean for the people themselves? Dr. Cynda Rushton: The consequences for clinicians at the frontline is cumulative, the moral residue that goes along with every day being confronted with these really challenging questions, where there aren't good answers. It's not like when you decide between two patients which one should get the ICU bed, that you don't feel a sense of regret, or for many clinicians, a sense of failure, that what I've just done is going to cause harm to somebody. That is not why I went into nursing or medicine. I went into nursing and medicine to benefit people, to do the very best I could to relieve their suffering. You're left with this residue of feeling I just caused harm, and that is a very heavy burden to carry when you often feel every day at the end of the day, have I done any good. Dr. Cynda Rushton: What's been challenging for clinicians, is many of them have asked themselves and have asked others, did I do enough? Did I do the right thing? What goes along with that is a kind of moral suffering that is beyond just feeling like I'm participating in something I don't agree with, to really seeing that chronic residue result in feeling like I have abandoned important values of my profession, of my life, of who I am. Rae Woods: Or your identity as a caregiver and a clinician. I will admit, I was talking to a friend who's in the clinical workforce. I won't name her. She said, "It's even hard now when we see un-vaccinated patients come in, because you don't want to treat them poorly, but there is this mindset shift when they come in that leaves a terrible feeling in their heart as a caregiver, but it's there." I like that you're calling out that it's not just about a decision of who gets a ventilator and who doesn't; it's this cumulative over time set of challenges that frankly has existed since the beginning of the pandemic. Dr. Cynda Rushton: Well, it existed before the pandemic. What the pandemic has made obvious is that these situations are not inconsequential. And while they may be episodic before the pandemic, they are chronic everyday experiences. The consequence of those experiences is what you pointed to is this erosion of my sense of my moral core, my moral identity. I've had colleagues say to me, "I don't know who I am anymore, that I have now participated in these actions every day that leave me feeling as if I've really abandoned things that are so vital and central to who I am as a nurse or a doctor." I've had nurses say to me, "Am I still a good nurse?" Rae Woods: This is breaking my heart a little bit. I appreciate your use of specific terms here. You said moral suffering. I think a lot of folks would look at these scenarios and call it something else. They would say our workforce is burned out. I'm not sure that's the right term here. What do you think? Dr. Cynda Rushton: This kind of moral suffering, the more intense form of which is moral injury, where this is seen as an erosion of our moral core, is not the same as burnout. It may in fact contribute to burnout, which is an occupational hazard. That's characterized by emotional exhaustion, which every clinician right now is probably emotionally exhausted. Rae Woods: That's an understatement. Dr. Cynda Rushton: Right. It leads to a sense of sort of cynicism, and that's one of the consequences of the accumulation of all of these kinds of factors is that we lose track of our ability to empathize with the people that we're trying to serve. It erodes our sense of personal accomplishment. What burnout is really about is a mismatch between the demands of the situation and our resources, internally and in our system. Whereas moral injury, I would say is often an experience that occurs retrospectively. People are beginning to realize as this pandemic has unfolded, "Oh my gosh, what have I participated in?" Dr. Cynda Rushton: So it's important, I think for us to get the right diagnosis, to be able to name this as not just a physical, emotional exhaustion, this is moral exhaustion. Moral exhaustion from every day having to make and participate in decisions that make no sense in many situations, and that are so contrary to the usual way that we approach them, that it's no wonder that there is a residue that goes along with it. Rae Woods: I like your use of the word diagnosis here. I fear that a lot of these feelings are locked up inside individual folks' heads. How do you recommend leaders go about diagnosing and figuring out what's the spectrum of challenges that my workforce is feeling or that individual people are feeling? Is there a way to help leaders understand and diagnose in the moment what's happening with their workforce? Dr. Cynda Rushton: Yes, and I would start with the very simple practice of wholehearted listening, because what tends to happen under crisis is we go to transactional communication instead of empathic communication. What we hear over and over again is clinicians say nobody's listening, nobody cares. I think we have to start by really being willing to listen to the stories however painful they are and holding that without fixing it, but allowing the emotions to be able to be held and honored. Dr. Cynda Rushton: So first we've got to create a space, a psychologically safe space where we can be vulnerable together. Right now that's hard to do because I don't think people feel safe in themselves, they don't feel safe in their work, they don't feel safe in their teams and their organizations, they don't even feel safe in their communities or their homes. Everyone feels at the ready waiting for the next threat to show up. So we have to really create spaces where that can happen and where we can name and honor what is true, because until we name it, we can't begin to heal it or to release it. Rae Woods: You mentioned earlier that these problems existed prior to the pandemic. Let me imagine a world where the Delta surge at the very least, wanes. I'm not going to say that the pandemic ends, but at least we're out of this particularly difficult moment. Will these difficult ethical decisions go away, and will the moral suffering go away if that happens? Dr. Cynda Rushton: Well, I wish it was going to be that simple. I doubt it. First of all, these kinds of ethical questions are part of being a healthcare provider. It is the case that it goes along with our work. What is modifiable though, is how we respond to them. That I think is where the opportunity is. Dr. Cynda Rushton: Denial that they exist is not a sustainable coping strategy. We have to actually turn toward these issues and say, "Okay, they are there. Let us engage in trying to understand the patterns in this organization that have contributed to them. How do we resource the people who are dealing with them on a day-to-day basis? What's missing from our own organizational architecture here that needs to be in place to recognize these issues more proactively, to be able to have systems where it's expected that people are going to bring these issues up, and we respond by saying, thank you rather than saying, 'Oh no, you're a problem because you're bringing up something we actually don't want to look at'." Dr. Cynda Rushton: I think we're going to have to get more comfortable being uncomfortable with these issues. There aren't easy answers, but we cannot turn away from them. We have got to turn toward them and we've got to figure out the balance between investing in things that help engage the inherent moral resilience of individuals in systems that have resources that are available to support them to do the right thing every time. Rae Woods: That's right. That's right. Just like we can't expect individual clinicians to make these horribly difficult decisions. We need to create a system, whether it's a triage committee or otherwise, that protects them. We also need to create a system that protects them outside of just decision-making that supports the workforce more broadly. Dr. Cynda Rushton: Yes. I'll have to say, you talked about heartbreaking. There's a lot of heartbreak in the midst of all of this. We've talked about mental health consequences of these kinds of situations. What we're seeing is clinicians are experiencing very significant mental health consequences; depression, anxiety, post traumatic stress disorder, and even in extreme circumstances, suicide. What organizations have to really think about is it's not enough to tell your employees that you have a benefit for mental health services when those services are not accessible and are not perceived to be transparent and trustworthy. Dr. Cynda Rushton: I have a colleague who is an incredible critical care nurse, who worked nights during the pandemic in a busy, intensive care unit. She showed up again and again and again. She realized that she had reached a point where she was not well in terms of her own psyche. She was experiencing symptoms of PTSD. She was feeling depressed. She asked for a leave of absence for 10 weeks. It took nine for her to get access to mental health services. That is a broken promise from an organization that communicates that they have resources. Dr. Cynda Rushton: There's a failure around mental health access as well. And alongside that are all of the barriers that get in the way of clinicians using them; fear of retaliation, compromise in their job status, their license. To there are some bigger issues in terms of not only the moral domain, but how do we actually make good on our promise for the people who have given so much that we actually are going to support you and make it possible for you to be whole again too. Rae Woods: I appreciate you sharing this story with me so much. What you're just beginning to scratch the surface on is the fact that there are even bigger risks that we're talking about here. There are bigger risks for the workforce. There are bigger risks for the trust-based compact between clinicians and their employers, frankly, between those hospitals and their patients and what it means to do high quality public health intervention in the United States. Rae Woods: There is so much that we could keep talking about in terms of what to do next, but I want to end by just giving you a moment to speak directly to the folks who are listening to this episode. Whether they are a clinician themselves, whether they are a clinical leader or in any other part of the industry, is there one thing that you want them to take away from this conversation or one thing you want them to do differently at their home organization? Dr. Cynda Rushton: We have to name what's true and the incredible contributions and the sacrifices and the unintended consequences of this pandemic. I think if there's one thing we need to do is to restore the humanity in our healthcare. What I mean by that is we need to restore the humanity for the people we are serving, but we equally need to invest in the humanity of the people who are delivering care. That means to really make a commitment to live our values of respect of equity and compassion for everyone, and that includes the clinicians who are providing care on a day-to-day basis. Rae Woods: Cynda, thank you so much for coming on Radio Advisory. Dr. Cynda Rushton: You're welcome. Rae Woods: I spend a lot of time on this podcast trying to give you a set of solutions, but today I really wanted to spend more time just understanding how big of a problem moral injury is and how it really is manifesting for our clinical workforce today. We cannot sugar coat this problem, but that doesn't mean that there's not something we can do. We've added some links to the show notes, because remember, as always, we are here to help.