Burnout as collateral damage

In Stress and burnout in intensive care medicine: an Australian perspective and Have the courage to act on burnout, Simpson, Knott and Corke have addressed a very important problem, not just for intensivists, but also for many of the other specialists who treat patients with life-limiting illnesses and support their families.

I would like to preface my comments by saying that what I have written below should not be taken as denying the great benefit that intensive care unit (ICU) treatment has and will bring to so many people – members of my family included – or that the problems I describe are universal.

Interestingly, burnout seems less of a problem for those of us who work in palliative care and look after very large numbers of dying people and their larger numbers of grieving relatives. While palliative care workers do experience stress like everyone else, it is less often because their patient has died. Perhaps palliative care is easier on the spirit than most other specialties because we expect all our patients to die and someone else has already told the patient before a referral is made (or the referral is the message). We can help patients feel safe and cared for by focusing our efforts on broadly improving their quality of life before they die, and providing support for their family over the period of dying and in their bereavement. One of our roles is to normalise death as the natural end to every life (including our own).

I think that there are a number of systemic and cultural factors that may contribute to burnout of intensivists (and others) in addition to those discussed by Simpson, Knott and Corke.

• Many people, even those with known illnesses, have not contemplated or documented how they would like to be treated, nor provided any guidance to their family, in the event that they unexpectedly lose capacity and are admitted to ICU.

• Many in our community have unrealistic learned expectations about our power to prolong life. As clinicians, we may buy into that hope. Unfortunately, even when there is little or no chance of the desired outcome, we may have great difficulty in deflating unrealistic expectations.

• I think that experienced ICU specialists often rapidly and intuitively identify a patient’s situation as hopeless, sometimes far earlier than anything we might measure. Once that happens they can feel quite hollow if they believe they must feign hope for the family and other clinicians. The words spoken by John Cleese in the movie Clockwise, “It’s not the despair, Laura. I can take the despair. It’s the hope I can’t stand,” reflect the distress of dealing with the need to express unsustainable hope.

• Believing that almost any admission to ICU can help a patient to recover, few community members understand the degree to which even a short admission to ICU of a frail elderly patient will accelerate their deterioration. Moreover, some believe that it is ageist to deny ICU admission to very old people with multiple comorbidities.

• The partitioning of health care means that one of a patient’s specialists may offer an organ-specific intervention while ignoring the context of the patient as a whole. The intensivist, who then assesses the patient holistically as unfit for the procedure and subsequent ICU admission, ends up carrying the opprobrium for denying the patient their treatment.

• In some ICUs, patients remain under the overall care of the doctor who is treating the condition or the organ system that brought the patient to the ICU. That doctor, who may have a very strong emotional investment in the success of their particular intervention, remains medically responsible for decision making about withdrawing and withholding treatment. On occasion, intensivists, who are responsible for keeping the patient alive, may have some difficulty persuading that doctor that it is time to stop, even when it is clear to everyone else that persistence is futile and burdensome.

• The successes of ICU in managing life-threatening events mean that not uncommonly, having prevented someone from dying, intensivists come to realise that their patient will never be able to establish or re-establish an independent life – this may be true at any age, from premature babies to the extremely old. They may then find themselves questioning what they have done and facing the emotional effort required to disentangle the patient from the technology that is keeping them alive and the hope that encouraged persistence. This poses huge challenges for the clinician, the patient and their family.

• Many of the complex decisions made in health care are based on a complex balance of probabilities overlaid with a substantial component of emotionally driven bias. Just as we tend to downplay the risks of procedures that we are about to undergo, we sustain hope by overestimating the likelihood that we will recover fully from a very severe illness. This is a particular concern in the care of extremely premature infants, where the likelihood of achieving independent adulthood is low while the probability of significant lifelong disability is high.

• I have heard a number of intensivists from around Australia say that, at times, they believe that what they feel they are obliged to do amounts to “torture”. I would find that unbearable.

While the emotional rewards of success are great, these examples highlight the cost manifest in the dissonance that arises when intensivists believe that the burden of treatment to which they must subject some of their patients far outweighs the benefits that are likely to be achieved. In order to accomplish what it does, high-tech ICU medicine requires that intensivists nurture hope and work at high intensity. However, it also demands a price. Some patients experience only burden and gain no benefit. For clinicians, at times trapped and powerless in the face of community and personal expectations and the decisions of others, burnout is collateral damage and a price of the successes.

Associate Professor Will Cairns is a palliative medicine specialist based at the Townsville Hospital and author of the eBook Death Rules – how death shapes life on earth, and what it means for us.

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