Read on Twitter
. @iwashyna asked "Why do clinicians sometimes feel distress providing goal-concordant care?"
I loved pondering all the responses.
Here is a summary thread of what I read. Main takeaway: It's not so simple where this distress might come from! https://twitter.com/iwashyna/status/1288613252474134528
I loved pondering all the responses.
Here is a summary thread of what I read. Main takeaway: It's not so simple where this distress might come from! https://twitter.com/iwashyna/status/1288613252474134528
1. Concern treatment isn't truly goal-concordant.
This could be because of a failure of communication; i.e., patients/families have been insufficiently counseled, as echoed by many, including @carolinedavismd, @vanessapho, and @ogi_gajic https://twitter.com/carolinedavismd/status/1288624000554291200
This could be because of a failure of communication; i.e., patients/families have been insufficiently counseled, as echoed by many, including @carolinedavismd, @vanessapho, and @ogi_gajic https://twitter.com/carolinedavismd/status/1288624000554291200
@Doclief adds this concern could also stem from knowledge that family aren't honoring the patient's wishes https://twitter.com/Doclief/status/1288828287502909440
2. Distress could arise because structural factors are causing a moral bind.
@leticiakawano and @jeanstey raised concern about wasting limited resources https://twitter.com/leticiakawano/status/1289016894754783232
@leticiakawano and @jeanstey raised concern about wasting limited resources https://twitter.com/leticiakawano/status/1289016894754783232
. @DrMeganHoseyPhD alternatively points out that structural metrics may not reward clinicians for providing goal-concordant care https://twitter.com/DrMeganHoseyPhD/status/1288628353029742592
3. Even if goal-concordant, clinicians my not be able to shake that they are causing harm.
@DeenaKCosta, @sv1121 and @jamchugh https://twitter.com/DeenaKCosta/status/1288644766738112512
@DeenaKCosta, @sv1121 and @jamchugh https://twitter.com/DeenaKCosta/status/1288644766738112512
. @DoctorBecki, @kellimor, and @renalricky also point out that they know they could provide EOL care that doesn't cause this harm https://twitter.com/kellimor/status/1289030749069352961
4. Concern about providing futile care was also a common answer.
@Orangetrees2, @papo_paliativo, @tacoemoji_Evan, and @HeyDrNik discussed this issue https://twitter.com/HeyDrNik/status/1288642218018963459
@Orangetrees2, @papo_paliativo, @tacoemoji_Evan, and @HeyDrNik discussed this issue https://twitter.com/HeyDrNik/status/1288642218018963459
@ChristinaChapMD eloquently described that emotional ambivalence may arise from a loss of shared hope https://twitter.com/ChristinaChapMD/status/1289000570079125512
6. Another common answer was that treatment might contradict physicians' own wishes or desires at the EOL @vitaincerta, @MaryJarzebowski, @msiuba https://twitter.com/vitaincerta/status/1288838036307009536
@PatriciaVFaria speaks of a social melancholy 
in this absence of shared meaning about life worth living. https://twitter.com/PatriciaVFaria/status/1288842537894117376
in this absence of shared meaning about life worth living. https://twitter.com/PatriciaVFaria/status/1288842537894117376
Where does this leave me?
1. Knowing whether care is absolutely versus likely futile is hard, especially in the ICU. Nearly every patient is really sick and could die. But some won't. https://twitter.com/iwashyna/status/1288643091918798849
1. Knowing whether care is absolutely versus likely futile is hard, especially in the ICU. Nearly every patient is really sick and could die. But some won't. https://twitter.com/iwashyna/status/1288643091918798849
2. Really knowing patients' goals is hard.
@sv1121 points out that goals can be complex,
https://twitter.com/sv1121/status/1288830883219243008
and
@docleif points out how hard it is to know goals for patients that can't speak for themselves https://twitter.com/Doclief/status/1288828827368644613
@sv1121 points out that goals can be complex,
https://twitter.com/sv1121/status/1288830883219243008
and
@docleif points out how hard it is to know goals for patients that can't speak for themselves https://twitter.com/Doclief/status/1288828827368644613
3. Some clinicians suggest time in the profession helps this moral distress abate. They come to see providing aggressive treatment at the EOL, when goal-concordant, as a way to honor the patient.
@LungDocDoug, @joshuaedowd, @DrSamuelBrown, @HalliePrescott https://twitter.com/DrSamuelBrown/status/1288620777579765760
@LungDocDoug, @joshuaedowd, @DrSamuelBrown, @HalliePrescott https://twitter.com/DrSamuelBrown/status/1288620777579765760
Finally, @joshuaedowd provides an excellent thread-within-a-thread on interrogating one's moral distress in these moments, considering if communication was clear, etc. https://twitter.com/joshuaedowd/status/1288808158408957953
Anyhow, this was such a thoughtful, and thought-provoking, discussion. I've begun to forgive @iwashyna for starting it during my twitter hiatus.
