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Moral distress, fatigue and compassion burnout echo through critical-care teams.

Submitted by Dr. B. Cload

This article is founded on collective conversations with emergency medicine and critical-care colleagues in Saskatchewan.

As intensive-care units are in the throes of COVID surge, health practitioners reflect and wonder at our achievements. During the Christmas holidays, we suggested in an article published on the SMA website: “Give of yourself now; be generous in spirit by protecting strangers and friends; be kind thorough distancing and limiting your bubble; see a future of hope by separating now. Give of yourself, so there is a future for the many.”

Today, we should recognize the fatigue, moral distress and constant struggle that enwraps health-care workers. “We worry that we will be thinly stretched; we worry that we will break,” we wrote in December. “We fear that we will not be able to provide the care that the people of Saskatchewan deserve.” Now, we reflect on our self-care and our participation in a robust societal pandemic response.

COVID inundates our ICUs. Moral distress, fatigue and compassion burnout echo through our teams. COVID victims require patience from medical practitioners and families. On life-support, patients stay uncertain for weeks, without catastrophic decline or improvement. This erodes the hope of families and the morale of the ICU. The resource burden is more than daily patient numbers, but also time; the emotional burden is from COVID stasis. There is a paradoxical struggle between being an overworked effective practitioner and a burned out — emotionally overwhelmed — less effective practitioner.

Statistical models have been poorly predictive. Variation in Canadian public health measures offer mixed successes. Our freedoms seem infringed without full benefit realized. Muddiness of predicted COVID control distresses ICUs through resource and manpower planning — overscheduling and under scheduling potentiates exhaustion. Parts of Canada (with similar public health measures to Saskatchewan) are aflame with COVID. Resources are limited more by skilled personnel than physical space.

'We speak with fear of what may be ahead'

A state of triage — rationing of ICU care — seems possible. Triage means patients unlikely to survive may be denied life-support. As we wrote in December: “Any rationing of care will be the consequence and sum of our individual actions. We, the people of Saskatchewan, are responsible.” ICU triage would be morally devastating for health practitioners; ICU triage would be devastating for patients and families. We speak with fear of what may be ahead.

Social media obfuscates COVID information, with some participants grandstanding and gaslighting while diluting scientifically validated public health advice. Through weight of media, effective vaccines have been vilified on rare complications where those complications are common in COVID infection. This continues the emotional and moral assault on the health practitioner: we see vaccine eligible unvaccinated COVID patients.

We are grateful for those who have been vaccinated and have isolated, protecting themselves and others. This appreciation is reciprocated by compliance with vaccines and public health measures that mitigate the burden on the system and its practitioners.

Our moral distress should lead to self-reflection. Physicians often overwork in bursts and take time off for self-care and recuperation. Schedules lend themselves to stacking of work in order to hoard time for other activities — a cycle of overwork, burnout and recovery. COVID has not allowed these recovery cycles but has provided an opportunity for reflection on our logistics, our balance and self-care.

'We should take the lessons that are offered us now as the impact of COVID resonates'

We should look to our own well-being as we look to the well-being of our patients, health-care system and community. What has failed and succeeded for us, our patients and our society? How have we protected our vulnerable populations? How can we modify chronic disease burden? How do we enable the socially and economically disenfranchised to protect themselves in a pandemic? We should reflect analytically with compassion, skepticism and temperance. We should take the lessons that are offered us now as the impact of COVID resonates.

In the emergency department, many of the presentations we currently see are not COVID but consequences of COVID — mental health, addictions (and medical disease from addictions), delays in elective surgery, and decompensation of chronic disease from lack of access or not accessing resources. Even if COVID is tamed, these diseases will be prevalent, requiring increased health-care resources, including critical care.

Remember the privilege invested in us as health-care workers. Understand in this struggle you are not alone. Recognize the succor that you provide your patients is in part the gratitude for your efforts and sacrifice. Provide the gentle but firm guidance to convey us through this pandemic: vaccines, public health measures and care improvements when applied and followed are effective. Be generous in spirit, be generous to yourself so you can be generous to your patients, your colleagues, your health system and your government. Be kind to yourself, your friends, your family. Look to yourself and examine your own behaviours as we examine the behaviours of our society. Give of yourself and to yourself, so there is a future for the many.

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