Burnout and heartbreak in the ICU

Three recent end-of life cases have made the news and have been widely discussed.  As an ICU physician, these cases all resonate with me in one way or another.

Even though many others have written about it from a variety of perspectives, I want to address what’s going on with Jahi McMath from the standpoint of the medical professionals who are taking care of her.  As a quick refresher, she’s the 13-year-old girl in California who has been declared brain-dead and whose parents have come into conflict with the staff at Children’s Hospital of Oakland over removing her from the ventilator.  The ethics of the situation have been widely discussed, as have the challenges of helping families understand what brain death really means.  The dialogue I am not hearing anyone have, however, is the one about the impact of caring for a patient with no hope of recovery on medical staff.

Fact:  Conflict is inherent in life and work.  I’ve recently written about the relevance of managing conflict in the workplace.  We also know that conflict (both professional and clinical) is perceived by up to 70% of ICU workers.  These conflicts lead to job strain, and are heightened by more severe conflicts.

Fact:  Job strain is related to burnout.  Amongst Norwegian ICU nurses, burnout (as measured by emotional exhaustion on the Maslach Burnout Inventory) is correlated with job satisfaction, job strain, and vulnerability.

Fact:  Ethical decision-making may be a risk for burnout in ICU nurses.  A recent Portuguese study showed a positive correlation between burnout and ethical decision-making, particularly on issues of withdrawing care, withholding care, or proceeding to terminal sedation.  Not surprisingly, these situations heighten emotional exhaustion.

I’ve seen situations in my own ICU when we, as medical professionals, recognize that we have exhausted our options for cure while families still struggle with letting go.  I’ve felt the stress and frustration of trying to find another way to communicate, using slightly different words, that I have no way to cure their family member, and that any intervention I might offer is likely to be harmful.  I’ve also seen the impact that this has on our whole staff, who are some of the most compassionate people I know; for lack of a more scientific way to put it, it breaks their hearts when we end up in that place.  I’m grateful to work in a place where we can have candid discussions and support one another through these episodes.  I honestly believe, and research supports, that open lines of communication are a key cultural quality in our ICU that keeps us from burning out.

It’s my deepest hope that the ICU staff at Oakland Children’s are being deeply supported by their system and one another.  I simply cannot imagine being in their position right now, and even though I’m not one of them, as part of the ICU family I can assure you that their hearts are breaking.