FEMALE SPEAKER: Welcome to Mayo Clinic COVID-19 Expert Insights and Strategies. The following activity is supported in part by an independent medical education grant from Pfizer, Inc. And is in accordance with a ACCME guidelines.

MICHAEL WILSON: Hi. Welcome to METRIC 2020. We are really delighted to have you and to host our first session of the Virtual Critical Care Conference. The topic today is, Humanizing the Intensive Care Unit.

My name is Michael Wilson. I am an assistant professor of medicine and an ICU physician at Mayo Clinic in Rochester, Minnesota. And I'll be pleased to host and moderate today's discussion. We are really fortunate to have a panel of ICU clinicians and patients to discuss the topic of Humanizing the Intensive Care Unit.

And before we get started, I thought we'd just take a brief moment to have each member of the panel introduce themselves. So we'd like to start off with Dr. Sam Brown. Can you give us a brief introduction?

SAM BROWN: I'm a physician scientist. When I do the doctoring, I'm a critical care doctor with training pulmonary and then do a lot of research. And a lot of the research that matters to me is done through the Center for Humanizing Critical Care at Intermountain Medical Center, which I direct, and brings together a group of nurses and psychologists and patients and family members and data analysts and physician scientists, to try to whittle away at some of these problems that confront all of us that participate in intensive care.

MICHAEL WILSON: Thank you so much. And next, we have Dr. Lioudmila Karnatovskaia.

LIOUDMILA KARNATOVSKAIA: Hi, there. I work in the intensive care unit that the Neoclinic Hospital. And in my other time, I do research on clinical outcomes of the ICU patients, particularly psychological outcomes, and real time interventions to prevent psychological morbidity after the ICU stay.

MICHAEL WILSON: Thank you so much. And next, we have Dr. Aysun Tekin.

AYSUN TEKIN: Hi. I'm an infectious disease physician. I'm from Turkey. I recently joined the [INAUDIBLE] in Rochester.

MICHAEL WILSON: Excellent. Thank you. And next, we have Eileen Rubin.

EILEEN RUBIN: Yes, thank you. My name is Eileen Rubin. And I am president and co-founder of ARDS Foundation, which stands for Acute Respiratory Distress Syndrome Foundation, which has been in existence for the last 20 years. And when I'm not overseeing the foundation, I'm involved in research, with what has to do with humanizing critical care for patients and families. I also am involved in patient engagement and advocacy. And this is one of my topics that's near and dear to my heart.

MICHAEL WILSON: Thank you so much. And next, we have Dr. Sumera Ahmad.

SUMERA AHMAD: Hi. I am also a physician here in the pulmonary and critical care department at the Mayo Clinic. And outside my clinical time, I'm engaged in research looking at meaningful patient-centered outcomes and using the Get to Know Me board as one of the tools in humanizing the ICU care.

MICHAEL WILSON: Thank you. And next, we have Mrs. Corinne Thul.

CORINNE THUL: Hey. I'm A chaplain at Mayo Clinic Hospital in Rochester, Minnesota. I work primarily with cardiac surgery patients in the ICU, and also transplant surgery ICU patients.

MICHAEL WILSON: Excellent. Thank you. And last, we have Dr. Ognjen Gajic.

OGNJEN GAJIC: Ognjen Gajic. I'm critical care specialist at Mayo Clinic. I was a critically ill patient. I was very fortunate to have the best and most humane experience that it can be done, which I shared. So I feel expertise from both sides of the field.

MICHAEL WILSON: When you were a patient?

OGNJEN GAJIC: And a physician, yes.

MICHAEL WILSON: Both as a patient and a physician. Well, thank you so much, everyone, for joining us. So to start off, I just wanted to briefly explore, how do we define dehumanization in the ICU? And how do we define humanization in the ICU? When we talk about this concept, what is it that we are referring to? And I might pose this question, Sam, Dr. Brown, do you have any thoughts on this?

SAM BROWN: You're right. I think they're too broad just to take. One is the one that the social psychologists talk about, which is that dehumanization is the failure to attribute a rich inner mental life to another entity. So it's an assumption that another individual, classically the concern is an individual of the species Homo sapiens. It's the assumption that the person you're interacting with does not have the same inner mental or emotional life that you do, that they are in some ways inferior to you.

And framed that way, it's incredibly common. I mean, all of us dehumanize at least a little bit each day. And in the most extreme versions, you can get up to national socialism in Germany and other forms of genocide. So there's a spectrum from being just a little bit arrogant on the one hand, to being a full-on genocidal maniac on the other. And that's the social psychology definition of it. And depending on the circumstance, culturally, medically, the condition of persons in at the time, the degree of dehumanization in the ICU is going to move in between those two extremes.

But then, there's the practical sort of brass tacks definition, which for me is twofold. Does the individual matter as a person? And are they allowed to belong to our community? There is an individual and a communal solidarity definition. And I think both of those are important as we think about the ICU. There's a sense in which, when you're in the ICU-- and this is not at all ICUs. And everybody on the call and many others have been working to improve this. But there is a sense in which, when you come into an ICU, you are stripped of the markers of your identity. And you are surrounded by people who do not welcome you into their community. You're surrounded by professionals who have their own lives that are quite independent of yours.

And there's been a tendency-- the nurses have done the best job historically at resisting this. But there's been a tendency to both eliminate the individuality of the person, putting them in identical prison uniforms, getting casual access to their body, including their genitalia, defining who their visitors will be or will not be, defining when they're allowed to sleep and wake, defining when they're allowed to experience pain or relief, that there is that component of eliminating the individuality and of not heeding their individual needs.

But also, the sense of maintaining these very strict barriers that can be very disorienting to the person experiencing this isolation, that makes them feel like they're not welcome to be a part of community. And I think, as Ogi and others will talk about, as we're thinking about pandemic circumstances, both of those become even more extremely stressed.

So I guess, there's the formal social psychology definition and then for me, the brass tacks definition of dehumanization.

MICHAEL WILSON: Yeah. Thank you so much. Really appreciate those thoughts. And Eileen, do you have any additional on that?

EILEEN RUBIN: Yes, definitely. I think when a patient is brought into an ICU, often they're in this condition where they may be on a ventilator. They may be in a medically induced coma. They may not appear to the people who are treating them-- even to their own families, it may not appear to be, as Sam was saying, like part of this group of people. They're laying there.

But patients take things in. So even if they're in a medically induced coma, they can hear things. They understand things. They just don't necessarily respond to it. So when a patient is in a bed and in this condition and they're being treated as though they don't exist-- so doctors or nurses may, not all of them, but they may come up to them, not say who their name is, what their specialty is. They might not say what it is that they're going to do to them. You know, without saying, OK, my name is Dr. So-and-so. And right now, I'm going to listen to your heart. So I'm going to take out this piece of equipment and touch your body, if that's OK with you. Even if the patient doesn't respond, the patient is hearing it. And that creates a humanizing situation. And also, it has the benefit of the family members, if they're present, hearing that doctors and nurses are also treating that patient in a humanizing way.

So this way, it creates a situation where they are part of the group. And they deserve to be treated as such, and not just as somebody who's just in the bed and I've got to do my job and be done with it. It's like, time needs to be taken, words need to be spoken, things need to be explained, and that patient needs to understand, even if they cannot verbally say, yes, I understand. Yes, this is OK. They need to have that idea that, this is happening to them and they're accepting of it.

MICHAEL WILSON: Thank you, Eileen. So now that we kind of have a framework of what the concept of humanization might be and what dehumanization might be, maybe let's speak a little bit about, how are patients in the ICU dehumanized? So I guess I'll open this up to the whole panel. From either your personal experience or from research or knowledge on the topic, what are some specific ways in which ICU patients might be dehumanized?

EILEEN RUBIN: One way for sure that stands out immediately is that, the staff doesn't use their name. They refer to them as, that patient in room 6 or something to that effect. So they don't really have an identity because they're not Charlie. Instead, they're just a vent patient in room 6. Or they might be just the latest condition that's happening to them at any given time.

MICHAEL WILSON: Thank you. Anybody else?

CORINNE THUL: I think when people, providers of any kind, don't greet the patient, but maybe turn immediately to family members, other loved ones in the room instead of introducing oneself to the patient, that can-- and it can be challenging. Even when a patient isn't fully understanding everything, I think that greeting and acknowledgment and just the general recognizing them as a human being is very important.

MICHAEL WILSON: And as you said, these are things that we might do in normal circumstances. When we walk into a room with a roomful of people, we may say, well, introduce ourselves and greet each other. But sometimes, what you're saying is that this may not happen when a provider enters into the ICU room of a patient.

EILEEN RUBIN: There are also occasions when somebody will need to do a procedure on a patient. And they're called into the room. And without any forewarning, regardless of what condition the patient is in, they just start to sort of manhandle the patient. And they start doing things. This is very dehumanizing. This is very disrespectful to the patient. They may not be ready. They may not be aware.

In my thought process, I always think that when somebody comes up to the hospital bed, they need to say who they are, what they're going to do, how they're going to do it, and why they're going to do it. And that's something, that information they need to offer to that patient. And I'm saying, regardless of whether the patient is in a medically induced coma or not, just so that they can have an understanding that they hear it, they can take it in, and they grasp the concept of what's going to happen to them now. And it's not going to be such a shock.

SAM BROWN: Mike, we call this the dinner party rule. Basically when you enter an ICU room, you follow the basic rules that you would observe at a dinner party hosted by someone you esteem. You introduce yourself, use their chosen name, you knock before you enter the room, and you ask permission or at a minimum, notify if they're comatose, before you touch their body. Just like you wouldn't walk into some celebrity's house for a dinner party, barge in the front room, use their name wrong, not say who you are, and grab them by the genitalia. This is something you would not do in normal dinner party encounters.

But I can't tell you how many times I've seen precisely that activity happen in an ICU room. I think we're doing better. I think people like Eileen and others have been calling attention to this. But just the basic rules of etiquette, because that's what you do with other human beings. You follow the basic rules of etiquette. And I think Eileen's right on in that emphasis.

SUMERA AHMAD: On that note, I would say that you've picked up a point, that process of dehumanizing patients really reflects a process of dehumanizing of the providers themselves. And whether it is how we have been groomed through our medical training, through our environments of wherever we have trained, and absorbed that this is the way one should be treating people-- and now recognizing that this really does not help patients in their emotional, psychological recovery, but it almost is reflective of an intrinsic problem in our own training and grooming as providers, I think.

LIOUDMILA KARNATOVSKAIA: And sometimes, the process of dehumanization can also reflect provider burnout. So it's a depersonalization that we sometimes use as a coping strategy so we do not get involved with the patient, so we do not spend the energy we don't have. And that's where this platform of interaction is most meaningful, how we can remain human to our patients, how we can tell them, sleep well, good morning, basic human words when we enter the room.

Especially now in the COVID era, when we have to wear protective equipment, it's even harder to stay in touch with the patient when we have all the masks and the PPEs and all that. So saying please, saying thank you, having them choose, maybe, where the procedure is being done, if possible, saying sorry if you were rude to them, these are the basic signs, basic words we should use in communication with the patient, particularly now in this time.

EILEEN RUBIN: And I also think it's important, you just mentioned burnout and things like that. And I think it's equally important that there's this kind of humanization that goes backward and forward between families and patients, as well as to the medical staff. The medical staff needs to have-- if they've just come off of a code or they've done something that was particularly difficult with one patient, they need to be able to take five minutes or whatever time that they can take, sit in a room, have a moment, get some music, just relax and destress from that moment so that they're fresh. And they're able to go into the next room not bringing with them what just happened in the last room, and bringing that baggage. They need to come in fresh, and this is a new patient, and be able to-- with exuberance or whatever the tone is of the day, need to present that to the new patient so that everybody is seen individually and not just another terrible day at work.

Because this is really easy to do. And if medical professionals do not get that opportunity to decompress and relax and get some space in between their patients, especially the challenging ones, then it's going to lead to worse burnout. And it's going to lead to less humanization of the ICU in general.

SAM BROWN: And I feel like the three of you have drawn attention to an important point. There's been this tendency to assume, in some areas, that it's just stubborn or even mean clinicians that are the problem. And clearly, some of us do bad things. I'm not trying to exonerate all of us.

But my sense is that hospital administrators and the people that designed the systems in which we all work and train are also on the hook for this. And you can't just send people an f-ing link to a mindfulness class or give them $10 off a yoga session and feel like you've done your due diligence, your responsibility as an administrator or leader for solving this problem. Because we're all in this together. The whole point of humanization is for us to allow ourselves to be all in this together, which means that all of us need to be thoughtful about the pressures and stresses and cruelties that we enact on patients and families, and also, the same pressures and stresses and cruelties that we put on the clinicians.

And I think that's a crucial thing that sometimes gets missed. There's an assumption that there's something morally defective about the distressed clinician that dehumanizes a patient. And that's usually not the case. Usually, they're exhausted or scared or they're operating in a system that doesn't work, or they've been trained in a way that's not allowed them to flourish in a difficult time.

You know, when we started these humanizing projects five or seven years ago, I early on got feedback from some frontline clinicians that said, Dr. Brown, you're dehumanizing us. And I realized that you can't just say, here's moral clarity. Let's fix this. You also have to be open and honest and introspective with the people whose behavior you're hoping to change.

EILEEN RUBIN: I would say, you can't just have like a $10 coupon off of a yoga class. You have to have something, even though space is limited in an ICU environment, like a room or a location where somebody can, if they want, scream, decompress, take a moment, just do something so that they can move on. They need something in that moment. A yoga class 12 hours later isn't going to-- it's going to be beneficial in some way. But it's not going to be beneficial in the right way that's needed right then and there, for that medical professional to move on to that next patient and to make it a more humanizing environment.

SUMERA AHMAD: I wouldn't mind sharing, on that note, Eileen, that back when I started internship, there was a lot of focus on being medically strong. But these items were not, per se, coached to be essential. Of course, people would call you out if we were caught just being rude. But it wasn't an essential thing that was taught.

Also, people have had these ideas that to be in, let's say, critical care or to be a surgeon or something, they consider in their minds as-- well, in layman's terms, let's say strong. You have to be aggressive. And it goes really-- it doesn't turn out well for the patient, in that perspective, of humanizing their care. But the mindset has been very different in many training places.

CORINNE THUL: We do regular debriefings with our cardiovascular surgery ICUs. And one of the really important aspects is trying to help our staff know that it's OK for them to attend. It's not saying that they're too weak or don't have what it takes, but to talk about the hard things that we're going through, the challenging cases, sometimes the difficult patients, that it's OK to talk about that. And actually, by talking about it, we can support one another and it kind of normalizes the challenges and allows us the time to really encourage very healthy choices.

I mean, we make choices when we go home, right? But not all of them are good choices. What can be real helpful connecting with people, so we can get filled up for the important work that's done. That aspect and also that, actually treating people with dignity feels good. When we know that we're part of helping a person who can't talk, who can't care for their physical bodily needs, who can't communicate-- I guess I said that one already-- can't breathe on their own, you know, when we are part of helping them to keep their dignity, that's a very satisfying aspect.

So where it can be some extra effort, also there's a sense of mutuality in that we're receiving a really good sense of value, meaning, and purpose when we're treating people with dignity. So we really work hard to lift up some of those aspects and to attend to the difficult parts for our staff.

MICHAEL WILSON: Thank you so much. So there's been quite a lot of discussion about the connection between quote unquote, "dehumanization of clinicians" and clinicians might be burnt out, they might be overwhelmed, they might be stressed, they might be in an unfamiliar environment, they might have too much on their plate. And that would be one of the reasons, potentially, why they may treat patients in a dehumanizing way, albeit probably not purposefully.

Aside from that reason, are there other reasons why patients are dehumanized in the intensive care unit? I mean, it's not something that we want to have happen. Are there other reasons why these dehumanization behaviors are occurring in the intensive care unit?

SUMERA AHMAD: Their disease makes them vulnerable to it itself, just not being in that situation to exercise voice, to exercise their expression itself is a very vulnerable state.

OGNJEN GAJIC: I think even worse is the things that were imposed on us or we impose on ourselves, obviously introduction of electronic records and all the meaningless charting taking away time of the nurse and physicians from the bedside is an impediment. And then, our fixation on meaningless numbers. We can talk about urine sodium for 45 minutes in rounds and not get to know [INAUDIBLE]. So those are some of the things that we contribute and the modern world does. And obviously, nowadays, with barriers and precautions and personal protective equipment.

[INTERPOSING VOICES]

EILEEN RUBIN: I'm sorry. I had an experience when I on a ventilator for eight weeks. But four of those weeks, I was not in a medically induced coma. So I was able to write. And one day nobody was in the room except me. And I had a pad of paper. And my pulmonologist approached my bed. And he was giving me an update. And I was jotting down notes. And I was looking down, and my writing wasn't the best. So I was slow, and I'm writing down my notes.

And I literally looked up, and only to see my pulmonologist turn his back and was walking out of the room. And from this day forward, I say, you don't turn your back on a vent patient. I literally tried to take that pad of paper and throw it at the doctor. I mean, I was so weak it missed. But I was literally in the middle of asking a question based on my care that he was giving me information. And he turned his back on me.

And it's easy, I believe-- and I think some people put thought into it. Some people don't. But I think it's easy, when you have a ventilator patient who is non-communicative, to be able to turn their back on them.

SAM BROWN: Another broader social question at play is, some scholars have called it the late modern meritocracy. And there's a lot that's been good that's been associated with it. But then there's been this move toward an assumption that people matter most on the basis of their skill or wealth or aptitude or power. It's an old notion, but it's really gotten baked into our societies in the global west over the last 50 or 100 years.

And what's complicated about the meritocracy that says you're only as good as your current excellent performance is that the ICU is the place where you have the people that are most vulnerable, most ignored and neglected within the meritocracy on one hand. Those are the patients.

And then you have clinicians, classically physicians but also others, who are really at the top of the meritocracy, right? Part of what we love about America is that anybody-- I grew up on welfare. Ogi came as a refugee from the Balkans. And you can become a physician or a clinician and can have really, a great life in the meritocracy. And part of what's necessary for the meritocracy to work is this understanding that people who are lower in this scale don't matter as much.

And I think a hospital, and particularly an ICU, is this bizarre moment where you bring the people who have won the game and the people who have lost the game. And you put the people who have lost the game in terrible crisis. And you overload the meritocratic winners. And then you ask them to create a community.

And at some level, it's not a shock that people struggle with that. And it's a reminder that it's not just how hospitals are organized. It's how societies and cultures are organized that can have an influence on what happens when the rubber meets the road in crisis.

MICHAEL WILSON: Yeah. Thank you for summarizing that, Sam. Now let's turn our attention towards humanization or the topic of, how do we address this. And maybe just to open it up again to everybody to say, how do we humanize patients? And what are some potential solutions to this? How do we take this difficult situation and some of the reasons we've explored, and how do we humanize patients?

EILEEN RUBIN: I have just a great story from when I went to visit an ICU. And when I was there during the lunch break, I gave my presentation about my story as a patient and the struggles that I went through. And there were many doctors that were listening to this on their lunch breaks and everything.

And afterwards, there was an ARDS patient that needed to be intubated. And the head of the ICU, who was known not to be very compassionate to his patients, as part of that procedure of the intubation of that patient, he sat there the entire time during the intubation and held the hand of this woman and comforted her during the entire intubation process. And it was like, something that was so notable and so out of character just from hearing the story of what I had experienced.

And so it's things like that-- there's little things that medical professionals can do. And that's just an example of humanizing the experience by calling people with their name, by greeting them, by talking with family and the patient, by learning information about the patient so that it's more than just a doctor-patient relationship. You sort of have a background about it. You know that this person likes this sport or that sport. This person plays guitar on their off time. What kind of job this person had forever or who they're married to or they have 13 grandchildren. Something like that makes it a more humanizing environment and a better environment for everyone involved.

MICHAEL WILSON: Thank you. Sumera, can you talk maybe a little bit about the Get to Know Me board and how that might be one idea or tool to humanize ICU patients?

SUMERA AHMAD: Sure. Well, the Get to Know Me board, a little background is, it came out of the palliative care realm when they were integrating their care in the ICU. And was typically one of those tools they were using to integrate care as an uplift-- a patient was dying from anonymity.

And so the Get to Know Me board is like a poster or a board, however it is formed. And introduces the person in his routine life, his hobbies, his activities, favorite food, a little bit about the family structure, accomplishments, to kind of take that human person out of the critically sick person, share it with the providers.

It's a tool, of course. We have to work on, how is it best used, how are people using it. Those kind of studies are underway. But like all these different tools, it's one of the ways, I think, that could really enable our approach or behavior modification in this process of humanizing the ICU.

And it's wonderful. These patients had shared with us the great story of him and Ogi. It is almost inspiring to hear his story, how it helped him to be uplifted out of anonymity, of being a disabled person in the ICU, to somebody very special, unique, and valuable.

MICHAEL WILSON: Excellent. Thank you for sharing. Liouda, can you maybe share a little bit with us about your work in an effort to humanize ICU patients?

LIOUDMILA KARNATOVSKAIA: Well, I think before I talk about my work, another reason why it's important to humanize the patients is, when patients feel that they're not attended to as humans, that will also increase their stress. And when patients are more stressed, it makes their disease course potentially worse. Because there's a lot of literature, how stress exacerbates disease. And we haven't talked about it. But it's potentially a selling point for clinicians who may not otherwise think why they need to address pneumonia in room 54 as a human being. That may actually get through to other people, because humanization can promote healing.

As far as my work, we are trying to do an intervention where we talk to patients about where they're at. We introduce ourselves. It started with physicians. And now, we have psychologists and we also have trained doulas who traditionally provide maternal care, but now they're also providing ICU reinsurance.

And we have psychologists and doulas, primarily, come to patients who are the most sick. They introduce themselves. They comfort the patients. They tell them where the patients are. They talk to the patients, that they're safe. They inform the patients about their disease course, about what happened to them, and they talk to the patients about what will happen in positive terms. So they reframe any negative experiences that patients have had, negative experiences they're currently feeling like noises and other things that are noxious and they try to be reframe potential procedures as a positive event, like a [INAUDIBLE], which usually is noxious. They explain that it clears the mucus from the lungs.

So it's an intervention that we have been doing every day on the patients who are intubated who are most sick. And the idea is that for anybody who is not involved in this type of work, one of the ways we can humanize our contact with the patient is to assume, like Eileen said, that they can hear. Because the indeed, can hear speech, even when they're sedated. And to talk to them, to let them know why we're doing certain things. If we're putting a line, let them know that we're putting a line in their necklace so that they can get medications to help with their blood pressure or to help their bacterial infection or whatever it is they're helping with, to tell the patients what will happen and why it will happen. That's a big part of humanization, besides addressing them as a human being and saying thank you and please.

MICHAEL WILSON: Thank you for sharing. And I know, part of my personal passion for this sort of work and this topic is listening to the experiences of so many patients. And I just am amazed at all of the times where I think that a patient is not aware of what's going on and they have said, I was aware of what's going on. And it's just that assumption that we, as ICU physicians make or some of us make that, you're asleep, you're in a medically induced coma. You're not aware of the paralytic being started, or you're not aware of the procedure, or you're not aware of the pain or the catheter being inserted.

And so I think that your interventions and your work explaining these concepts to people who we assume may not be aware has real potential. Thank you.

Sam, can you explain to us, some of the interventions that you have been working with to try to improve humanization of ICU patients?

SAM BROWN: Yeah. We have some interventional trials and we've done some more QI, operational implementation kind of stuff. I want to highlight the work of Sarah Beesley, B-E-E-S-L-E-Y, in our group. She's a bright, young investigator who's really spearheaded what I think is crucial, really process work. Because what you realize is, it's very hard to microengineer the development of communities and to give strict rules for, this is what you do in this situation and not in this situation, and this context changes that. It ends up getting sort of impersonal to have these long lists of all the cans and can't dos.

But it seems to me that our core point is to build these little communities meaningfully. So we thought, well, what are the processes that interfere with that? And Dr. Beesley's really been leading this work and doing a phenomenal job. And you know, one of the first things we did was, we said, there are no clinician-based visiting hours. The only visiting hour restrictions are those imposed by the patient and her family themselves. And we did that maybe eight years ago, published their experience there.

A couple of nurses quit. They said, I didn't sign up to always be bombarded by requests from family members. But mostly, people said, oh, this seems like the right thing. Let's proceed.

And then something that we've been doing now for almost 10 years, it feels like, is family procedural presence. And Dr. Beesley's just writing up now the results of a big intervention there. But the argument is that, you're scared. You're about to undergo something very disorienting and uncomfortable. And why on earth would we restrict from your bedside the people you love at this time of crisis?

So we developed these ways. They're pretty easy to do. I've done hundreds upon hundreds of central lines, intubations, chest tubes, whatever. If the patient wants them there and they want to be there, they're there. We screen them for whether they're at risk for fainting, that kind of stuff. But in hundreds of hundreds of circumstances, we've had maybe two episodes where a family member was unexpectedly intoxicated and had an outburst. No harm done at all. The nurse gently walked him out. And that's out of hundreds of these that we've done.

And to the contrary, what we're finding is, family members get along better with staff, feel more included, feel more supported, if they know that they're not going to be arbitrarily excluded from the bedside. And I think something as simple as just that, saying, if our goal is to humanize the patient and we have easy access to the world expert in the humanity of this patient, why would we banish the world expert in the humanity of the patient from the bedside?

It's like having a patient with a flail mitral leaflet. Sorry, I'm getting all technical. But it's like having a patient who needs emergency cardiac surgery and saying, sounds great, but the cardiac surgeon is not allowed to come visit you, right? I mean, so for us, it's this question about, who are the world experts in humanity? Do not categorically exclude them and loop them in. We have on rounds, they are invited to spend the entire rounds with us. It's not like we do the real work and then answer some questions. Family members are invited to join the entire round's experience with us. The only visiting hour restrictions are based on the patient's desires and family procedural presence.

And we feel like that bundle of interventions that Dr. Beesley's been leading have really been some of the most straightforward work, to just get people being creative and thoughtful about what the next steps ought to be.

MICHAEL WILSON: Thank you so much for sharing.

EILEEN RUBIN: Can I just say something based on what Sam just said, really quickly?

MICHAEL WILSON: Sure. We just have a short period of time left.

EILEEN RUBIN: OK. All right. So when I was in the ICU, I was just out of my medically induced coma. They had reduced my paralytics extremely. It was late at night. And they decided they wanted to transfer me from my ICU room where I knew everybody, my nurses, the doctors there, everybody. I had three family members with me. They kept telling me I was getting better, I was getting better. I knew I wasn't getting better.

And they, late at night, transferred me from ICU to a ventilator floor where I had new people, new staff, a new environment. I was getting very agitated as this whole process was going on. I was getting totally shook up. My hands were shaking. I was evolving into a total mess.

And then, once they got me into this other room, again, with having no paralytics-- having the reduction of paralytics, the move in the middle of the night, and strangers there, they then yanked my family and told them that it was the end of visit visiting hours, they had to leave. So they're effectively taking me out of a safe environment where I felt OK, and putting me into this terribly unsafe environment where I couldn't communicate and talk. And it was totally exactly what was going on. You need to have these people, your family members, they're the people that are going to support you and they're the people that are going to be championing your cause, and for the most part, not getting in the way of things.

You need them there. They're going to make you less anxious, less depressed, and a better patient.

MICHAEL WILSON: I'm so sorry that happened to you, Eileen. And thank you for sharing that experience with us.

I want to just pose two final questions. And I'd like to direct these questions to Aysun Tekin and Ogi Gajic. And so the first question is, Dr. Aysun Tekin is from Turkey. Can you explain to us a little bit about humanization in the intensive care unit in Turkey?

AYSUN TEKIN: We are extremely careful about the conscious patients, getting in touch with them, communicating to them in a proper way. But with the comatose patients, we try to be careful. But due to the work around or things like that, it might be kind of overlooked from time to time. But we are trying to be careful.

MICHAEL WILSON: Yeah. Thank you so much. It remains a challenge in lots of hospitals and lots of different types of settings.

OGNJEN GAJIC: Aysun, do you have visiting hours? Can the families come in the room all the time? Or how long they can be there?

AYSUN TEKIN: They can't come into the room all the time. We have a visiting hour. And we can take on the one relative for one patient for the day. So that's a pity, actually. But we have that.

MICHAEL WILSON: Thank you for sharing. And right now is kind of a time of pandemic with COVID-19 coming in and lots of new challenges faced in the intensive care units. Ogi, can you explain to us a little bit how we can humanize patients, even in these new uncertain times? And maybe increased workload in the intensive care unit?

OGNJEN GAJIC: Yeah. Thank you. I think so. I've been really learning and the internet is filled with your guys humanity of both clinicians and our chaplain and Eileen as a patient and Dr. Brown with his deep understanding of social sciences. So thanks for this panel.

Obviously, the pandemics and inability to get in the room without the full equipment and a mask that no one can see you is a huge barrier. And as you could see from our colleagues that experience it in China and our colleagues in Italy, we are getting, with regards to humanization, to 1980s care with literally all about numbers and absolutely no way. Families are not allowed. Clinicians are not allowed in the room because they can get infected. So everything is minimized.

Yet I would just put a parallel to the whole life. So we have this word, social distance, which is ridiculous. I think the word has to be replaced with physical distances and social gatherings. So this social gathering that we five or, I don't know how many of us are having now, brought us very close together, although we are miles away, actually, through technology. So I can just share that this is not research. There is nothing to do.

I can share a single experience of my patient with COVID that I took care of last week over several nights, as we cover tele-ICUs in remote locations. So the patient's intubated, paralyzed, ARDS. Apparently, I come on taking the paralytic [INAUDIBLE]. And I start because he can see me on the screen, like you guys can in the TV screen, that's how the e-ICU works.

And I realized very quickly that I was the only face, human face that person has seen in several days, because everyone else was like, you know, completely like a robot or like an astronaut. And so I started talking. OK, you're safe here. That's what I do. And I said, here. Because it's there, it's miles away from here. But I said, you are safe here. You have bad pneumonia. You're on a ventilator. You're getting better already. We'll see when we can take this tube out.

And I could see his heart rate going down and grimacing, OK? Even sedated. So that was very encouraging. The next day I come-- so then we were just stopping stuff, you know, going down on usual stuff. The next come up, I come usually, we cover from 6:00 PM onwards. So I come the next day. And immediately, the first thing I do after I sign out, I go directly to his room. Again, he's lonely. There is no one in the room because no one wants to be in that room.

And now, during the day, as we stopped everything, the pulmonologist who came in the day was able to extubate. He's kind of teetering in there. He's like breathing 35 a minute, you know? Just kind of a close call. Because my sign out was, maybe he's going to get re-intubated. And they were worried that they did it too soon.

So I said, again, he's delirious. He doesn't really know exactly what was happening, on a high flow oxygen. And I said again, you're safe here. Take nice and slow breaths like yoga, just the stuff. And he sees me. And I can see that, he said, doctor.

And I did what Liouda has taught me. And she teaches the doulas and psychologists, some of this what is called positive suggestion. But basically, human, just human, I care. I care about the patient. I'm doing it to him like I would do to my family.

The next day I come, he's better. He's less delirious, a little bit. And then he comes as soon as I show him the face. Hey, doctor. He goes, I was the only person he could recognize because he remembered me, OK? And then we did like-- we didn't fill out anything. But we went through it. He's a truck driver. And he was-- obviously, I don't want to share now all of the fascinating stuff about him. But he's actually a very fascinating person. And tomorrow, he's an [INAUDIBLE] ICU, OK?

So for me, I don't know how it helped him. I don't know. Personally, I believe like Liouda that it probably saved him re-intubation. But that aside, it increased my humanity to the extent that I can do this in a very, very difficult time. So put everything in there like some kind of an iPhone, iPad, I've had interpreters that can be used now for this. Have something that family, us can communicate to this patient. You cannot touch the patient, but you can-- sorry. That's all I can say about it.

CORINNE THUL: I think it's so important, the points that you're making, to be in the ICU is an existential crisis for patients. Their actual existence is questioned. Are they going to make it? And so whatever can be grounding and help them to feel their humanity and that they're not alone, it's really a beautiful story.

OGNJEN GAJIC: It's a true story.

CORINNE THUL: Yeah.

MICHAEL WILSON: Thank you so much for sharing. We have maybe one or two minutes left. We might just end on that note. Does anyone on the panel have anything burning left to say? I think we'll just end there.

I would really like to thank everybody for joining us today, each of our panel members for the experiences and thoughts. And you can really get a sense that you care about the lives of the people that you're treating and of the ICU patients.