Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And joining me today to highlight the intersection between burnout, end-of-life issues, and team engagement in the cardiac care unit is Dr. Sarah Chuzi. She's an Assistant Professor of Medicine and Cardiology at Northwestern Medicine.

Dr. Chuzi, thank you so much for joining us. What a great topic we're discussing here today. I'd like you to start by telling us a little bit about yourself, how you came to Northwestern Medicine and your interests as far as our topic goes today.

Dr Sarah Chuzi: Thank you so much for having me. I am, as you mentioned, an Assistant Professor of Medicine at Northwestern. I'm actually an advanced heart failure and transplant cardiologist, and I'm also a member of our Clinical Ethics Committee here at Northwestern. I have been here since medical school and really have just loved this program, this institution so much, really fell in love with Chicago over 10 years ago, and I have stayed ever since.

And I, many years ago, developed an interest in serious illness care. I find the most compelling patient care to be that which occurs when patients are incredibly sick, when they're at a very vulnerable time in their lives, and that includes sort of end-of-life care. And so, my interest, which I can talk about in this podcast, has really been the intersection of Palliative Care and Cardiology. And so, this is how I sort of ended up speaking here today on this topic.

Melanie Cole, MS: Thank you for sharing that. And I love Chicago too. So, right there with you, and thank you for saying that. Can you share your perspective on the intricate relationship between burnout, end-of-life care, and that team engagement within the critical care unit? Speak about this topic and why this is such an important discussion to have.

Dr Sarah Chuzi: So, this is actually a topic that I was really excited to speak about recently at our American College of Cardiology annual meeting in Atlanta. And the focus of this session was on certain aspects of ICU care that contribute to burnout and moral distress among clinicians. And in particular, I talked about this concept of medical futility, because I think this is really central to a lot of the issues that we're talking about. Futility is a really hard topic to discuss for physicians as it brings up a lot of emotions.

So when clinicians talk about medical futility, you know, often we're referring to a treatment that we feel like is just not going to work, or it's not going to lead to a good outcome for a patient. And when we feel like this and we're providing care, that often really contributes to moral distress. And that's just a feeling of sort of anger, guilt, frustration with the care that we're providing.

But there's actually been sort of a reframing of this concept in the literature, and it's recommended that we actually refer to these interventions as potentially inappropriate care. So, this just refers to a treatment or an intervention that has a small chance of achieving a desired outcome, but that we feel like conflicts with some core ethical principles or values in Medicine.

And so, you know, sometimes in Medicine and especially in the ICU, we get into situations where a patient is critically ill and their family or the patient is hoping for an intervention that the clinical team feels like is potentially inappropriate. And these situations often involve decisions at the end-of-life. They often involve feeding tubes, dialysis, intubation, ventilation. They're incredibly common. But when there's a conflict, like I said, between a clinician's values and ethics and the desires of a patient or family, this can lead to a lot of inner turmoil, especially for the clinicians. So, the session that I participated in spoke to how these issues all intersect and how team engagement can really help us navigate some of these challenges.

Melanie Cole, MS: In your personal view, how do you see burnout manifesting among these healthcare professionals in the CCU, particularly concerning the end-of-life situations and futility, as you say? What have you seen?

Dr Sarah Chuzi: I think the cardiac ICU is an amazing place. The technology has evolved so much over the past few decades, and we have the ability to use a lot of devices and procedures that just haven't been available to us in prior eras. But this also presents some really unique challenges, because we do have so many novel devices and treatments, it can be really overwhelming for patients and sometimes clinicians to understand what is the best option for a patient. Just because we have an aggressive or intense intervention doesn't necessarily mean that that's the right choice or that that aligns with the patient's values or goals. Further, we're often having to make these big decisions in a really short amount of time, as it's such a high-acuity unit. And so, I think all this is really hard and can lead to burnout, and just the feeling that, we're overwhelmed.

And the other thing I'll say is that, you know, the studies have shown that patients in our cardiac ICUs are older now. They're more medically complex than they used to be. And so, figuring out how to provide care that's aligned with a patient's goals and values in the context of their other medical conditions is also really hard, but is also very necessary. And so, I think these are just some of the issues that we face in our contemporary ICUs that can lead to burnout if we don't have the right tools or skills to sort of address these challenges, both with patients, but then with ourselves.

Melanie Cole, MS: Yeah. That's so interesting. And as you're telling us about balancing compassionate end-of-life care, which we all know is taxing on its own with maintaining your team morale and engagement, elaborate for us on any initiatives or programs implemented in your practice at the Bluhm Cardiovascular Institute aimed at mitigating burnout and enhancing team cohesion when dealing with end-of-life scenarios in the CCU.

Dr Sarah Chuzi: So, there's a lot in the media, I think, especially since the COVID-19 pandemic. There's been a lot written about clinician and healthcare professional burnout. And I think a few interventions here can be particularly helpful. And some of these are obvious and sort of low-hanging fruit, while some of them take more effort, but they might be higher yield.

So number one, I think self-care and boundary-setting are very important. And we know that when healthcare professionals don't get enough sleep, when they're overworked, they're at risk for burnout. And along these lines, I think professional mental help is very important. I think in healthcare, we think that we are supposed to be so strong all the time, but the reality is that we witness a lot of really challenging situations and this wears on us. And so, I think as clinicians, we just need to normalize mental health challenges, or even just the need to take a step back and take a breath or a break. So, that's number one.

Number two, I think we need to keep working as a community to address the root causes of burnout. This includes things like addressing staffing shortages, improving sick policies, improving parental leave, enhancing programs to help physicians with burdensome tasks like prior authorizations and, interfacing with insurance. I think all these healthcare system changes really have a big impact on wellbeing.

And then finally, I think, as a community, we need to work to cultivate resilience. So, resilience just means this ability to focus on the positive aspects of your job and finding meaning and connection, even when things are hard. And there's actually a lot of research that having more resilience can mitigate the downstream negative impacts of burnout. And I think the Bluhm Cardiovascular Institute is very aware of all of these things and has taken some bold steps to try to address them.

And in particular, I'm really excited to be leading a new initiative that's funded by the Bluhm Cardiovascular Institute. I'm heading a new program called COMPASS, and this stands for Comprehensive Palliative and Supportive Services for Patients with Cardiovascular Disease, and in particular, it's for patients with congestive heart failure. And COMPASS is, as I said, a new program. The primary goal is really to support patients with cardiovascular disease who are at high risk for poor outcomes and poor quality of life. In particular, our team is trained in discussing prognosis and goals of care. We will provide holistic, compassionate care. And we also will understand what resources are available to help support patients outside the hospital. But our other goal is to help support staff. So, we will support staff in debriefing and communication training, and just providing emotional support. So, I think this is just one example of a program that the BCVI has funded to sort of help tackle these end-of-life and burnout issues in a unique way.

Melanie Cole, MS: Dr. Chuzi, as we get ready to wrap up, and this is just a fascinating discussion we're having today, I'd like you to speak, as you were telling us about self-care, resilience, the things that can really help to prevent this burnout, especially within the bounds of the CCU and end-of-life care, I'd like you to speak about the role that team collaboration plays, because relying on peers, peer support is so important in many aspects. And while you're telling us that, anything else you'd like the key takeaways to be for other physicians from this discussion today about end-of-life care, burnout within the CCU and really this important topic?

Dr Sarah Chuzi: So as you said, Medicine is a team sport. We cannot practice Medicine or take care of patients alone or in silos. And so, it is really essential to cultivate meaning in your work, to make connections, not only with patients, but with colleagues. And so, I think in addition to feeling like you have an inclusive and welcoming environment within your own unit or division, I think it's really important that we learn to collaborate and build bridges with other clinical teams.

So in particular, something that's really helpful for us is our palliative care and our ethics teams are so helpful in a variety of clinical scenarios. They support our patients as the patients are navigating complex health situations, but they also support our staff and our colleagues. And they hold debriefing sessions with us after a patient has passed away or if we've encountered a particularly tough situation. And so, I think we need to recognize that clinicians and staff grieve as well, and really cultivating this practice of debriefing and building resilience, I think, is really important.

And so, you know, just in terms of things that are important to know about this topic as we wrap up, as I said, I think Medicine has changed a lot over the past few decades, not just in terms of the actual treatments that we have, but just in terms of the culture. And I think there can sometimes be some intergenerational conflict where people who trained or who worked decades ago feel like the current generation just maybe needs to be tougher. But I think that really doesn't take into account the challenges that clinicians face in healthcare today. Things have become much more complicated. And there are just a lot of barriers to finding meaning in your work. So, I think the focus on wellness, burnout, team engagement is really important and really warranted. And so, I'm really grateful to have been invited to speak on this.

Melanie Cole, MS: Thank you so much for joining us and sharing your compassion, passion for this topic and your incredible expertise, Dr. Chuzi. Thank you again. To refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/cardiovascular to get connected with one of our providers. And that concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. Please always remember to subscribe, rate, and review Better Edge on Apple Podcasts, Spotify, iHeart, and Pandora. Until next time, this is Melanie Cole.