Pandemic Lessons About Human Caring
An Open Letter to Leaders of Healthcare
Dear Colleagues,
This pandemic is far from over; indeed, it looks destined to become the Covid-19 endemic. As I write, American healthcare remains in crisis from the Delta and Omicron variants. Our daily agendas remain dominated by critical urgencies. Nevertheless, it is time to take stock of what we’ve learned from the challenges and suffering of the past two years. Pausing to reflect is necessary to avoid repeating the same mistakes during phases of this crisis yet to come — and in facing the next natural disaster.
People who lead teams, departments and organizations tend to recognize that life’s most valuable lessons are often delivered during the hardest of times. Adversity strips away pretense to reveal what really matters, distinguishing must haves from nice-to-haves and aiding the key leadership task of prioritizing this over that. This pandemic’s harsh realities have left little doubt about what matters most, both professionally and personally.
Here is a brief survey of pandemic lessons that I will be carrying forward.
Lessons for Healthcare
March 2020 awakened those in positions of leadership within healthcare to the cold reality of our threadbare workforce, frayed systems, and vulnerable supply chains. Suddenly patients with this novel coronavirus were streaming into America’s hospitals. Within days, the streams became torrents. Patients arrived sick and many rapidly became sicker, straining our facilities and suddenly, shockingly threatening clinicians’ ability to provide the best care to each and every critically ill person we serve. Even as hospitals cancelled all elective procedures and converted recovery rooms to ICUs, unending floods of patients revealed that we hadn’t stockpiled nearly enough respirators, surgical masks, gloves, and gowns. It was a terrible way to realize that we were woefully unprepared and to learn that disaster planning is essential to our jobs.
We also had to confront the unavoidable evidence that people of color, immigrants, and those who live paycheck to paycheck, or who have no jobs at all, endure far higher health risks than middle-class, white, English-speaking Americans. COVID-19 provided a masterclass in the myriad ways that housing, transportation, and workplace conditions impact people’s health. May we never again ignore these lessons.
As we were forced to impose infection protection protocols that distance clinicians from the patients we serve and severely curtail hospital visiting, we were poignantly reminded that families are essential to good patient care and human relationships are essential to human well-being. And when physicians and caregivers were driven to reuse and recycle single-use masks and PPE, we were painfully reminded that the safety and well-being of our coworkers must never again be taken for granted.
Necessity is the mother of invention — and innovation. We found that we could MacGyver solutions, such as locally producing our own disinfectants, masks, and rudimentary protective equipment. We quickly adapted omnipresent wireless tablets and personal cell phones to maintain contact between patients and the people who mattered most to them.
In the midst of this full-blown public health crisis, we were reminded — are continually reminded — that what matters most is life itself. The pandemic highlights both the fundamentals and full scope of our clinical goals and aspirations. In spring 2020, as my colleagues and I wrestled with how to provide the best care we possibly could in these unprecedented times, I sketched a hierarchy of human caring.
Building from developmental psychologist Abraham Maslow’s hierarchy of needs, this pyramidal framework offers a way of conceptualizing the continuum of caring well for people through the end of life.
Biological and social necessities of life form the base of this pyramid. Providing shelter from the elements — a clean, dry bed — and something to eat and drink are rudimentary responsibilities that define a caring society. This fact was made starkly clear by strained health systems and fractured supply chains — compounded in several regions by severe hurricanes and flooding — for groceries, essential goods, and essential workers.
During those early dark days of this crisis, we rediscovered an age-old truth; that the best way through natural disasters — floods, fires, famines, or epidemics — is together. When businesses, restaurants, and classrooms were forced to close, we learned anew that “community” is not an abstract concept, nor a static entity, but rather a living fabric of interwoven, mutual responsibilities. Seemingly overnight, schools and auditoriums were repurposed as public shelters. Chefs donated their time and talents to community kitchens, as well as precious food that had been intended for paying customers.
Heartening examples of clinicians’ unwavering commitment to high-quality care were also evident. Hospital teams quickly developed new ways of doing routine tasks. They choreographed procedures for rotating patients into and out of prone positions. Because masks and PPE obscured caregivers faces and expressions, clinicians began wearing face-behind-the-mask pictures on their chests to introduce themselves to patients. At Providence, my own health system, we expanded use of “Get to Know Me” posters, recruiting families of patients to remind all who entered their loved one’s room that they were caring for a whole person.
COVID-19’s propensity to cause rapid respiratory failure highlighted the importance of aligning what we do for people with what matters most to them. Within Providence we expanded use of Trusted Decision Maker (TDM) declarations, a way of eliciting and recording within their health record a patient’s verbally expressed values, preferences, and priorities. The TDM documents a patient’s choices for who should speak for them and what level of treatments they would want — or want to avoid — in life-threatening circumstances. We used cell phones and video technology to conduct virtual visits and hold sensitive conversations. Palliative care teams supported frontline emergency and hospital medicine colleagues in conducting goals-of-care conversations with communication tip sheets and just-in-time consultations. In a few of the hardest-hit hospitals, we established pop-up goals-of-care clinics to engage patients and families who might not otherwise have been able to have these conversations and express their personal wishes.
Clinicians consistently ranked restrictions of family visitation as the most stressful barrier to practicing during the pandemic. While there is no substitute for actual presence, touching and being touched by someone you love, necessity engendered creative ways of fostering and strengthening loving connections.
People blew kisses across FaceTime screens. Families gathered by Zoom to say the things that matter most — the gratitude, forgiveness, and love that might otherwise have been left unspoken. I carry images of such meetings in my mind’s eye. A hospitalized elderly woman with high-flow nasal oxygen stares at a laptop screen while 10 members of her family honor and celebrate her. One of her sons is caught in mid-sentence and half-smile, another holds back tears while trying to smile; a couple cradles their infant before the camera for a great-grandmother to see; a teenage grand-daughter stares in wide-eyed silence.
Amidst the suffering we have collectively witnessed, there have been uplifting instances of loving care and human well-being. These lessons too must not be ignored. Human beings are mortal and our physical health will inevitably decline. However, by extending the basics of human caring, even seriously ill and dying people may be able to love, feel loved, and at least occasionally to feel joy.
Because we aim high, we were able to provide good care, even when we were unable to deliver the full extent of whole-person caring to which we aspire. Thankfully, we have not had to compromise on the fundamentals. There’s been no shortages of essential medications to alleviate physical suffering. Patients still have had clean, dry beds. We have continued to innovate ways of connecting people within their families. We are continuing to strive to honor each and every person’s inherent dignity and worth.
Lessons in Resilience
This pandemic’s most profound lessons have been personal. We have been shaken from the illusion of safety, security, and a confident future.
The toll has been most evident on clinicians. More than a few became infected. Every one of them is exhausted, and none have escaped emotional trauma. Burnout was highly prevalent among clinicians before the pandemic. Now it is ubiquitous. Clinicians are leaving healthcare at unprecedented rates, often reporting post-traumatic stress. Those who remain must accept ongoing traumatic stress as an unavoidable aspect of their current work experience.
Healing is possible but it will take time. Healing is commonly talked about as becoming whole, which can give rise to misunderstanding. A return to life “as if it never happened” is impossible. After the loss of a limb or a debilitating physical or emotional trauma, authentic healing must integrate the facts of one’s suffering and the parts of oneself that have been lost or damaged forever.
Healing also requires that a person wants to be well. Sometimes traumatized people wrestle with feeling unworthy. “Was it my fault?” “Did I do enough?” “So many other people were hurt so much more than me, am I being overly sensitive?” Loving oneself enough to feel worthy of healing is necessary to take the first step. Sometimes a person needs to “act as if” they feel worthy to begin the process. Said differently, feeling worthy of well-being can be a decision.
It turns out that personal well-being has less to do with steel-like strength than an ability to bend and adapt. Resilience is river-like. Each spring in returning to the Montana rivers where I fish, I observe new obstacles that weather and gravity have inflicted. Downed trees or rockslides have cut off established side channels and created snags in river braids that were once navigable. It’s apparent how opportunistic, steadfast, and creative rivers are. They may be held back for a time, diverted and forced to change course, but they always find a way through.
Those qualities resonate with me and suggest a meaningful path for healing that does not deny the damage and losses endured along the way.
This pandemic has taught us to keep our aim high and our view long. We have learned that individually and collectively, we have the capacity for going forward by adapting and innovating in real-time, changing tactics and shifting direction when necessary. We now know that we will emerge irrevocably changed, but that well-being is possible.
