I Can’t See From Here: Exploring the intersection of nursing theory and palliative medicine

I Can’t See From Here: Exploring the intersection of nursing theory and palliative medicine



good morning my name is barbara ville i'm the fellowship director for the nurse practitioner palliative care fellowship at dana-farber which is part of the harvard interprofessional fellowship and i'm very proud to introduce kate shaka who is a nurse practitioner in the harvard interprofessional fellowship this year she received her Bachelor of Arts degree at the University of Denver and studied in biology and international studies she moved to Boston in 2012 and studied at Northeastern University receiving both her Bachelor of Science in Nursing and her Masters of Science in Nursing she also worked as a graduate student both as a teaching assistant at Northeastern and volunteered and Ana at a elder wellness and health education program here in the Boston area on topics ranging from end-of-life to nutrition and depression she worked at Brigham Women's Hospital as a registered nurse on an integrative teaching unit for four years before being accepted into a fellowship in 2018 and she will continue her work as a PI care specialist in July as a nurse practitioner on a newly created embedded palliative care team for advanced kidney disease at Brigham and Women's Hospital so happy to meet her she'll be talking about I can't see from here exploring the intersection of nursing theory and palliative care [Applause] so as Barbara said my name is Kate chakra I am a nurse practitioner fellow over at Dana Farber in Brigham and Women's and I will be talking today entitled I can't see from here exploring the intersection of Nursing theory and palliative medicine so a few housekeeping details I have no financial disclosures the objectives of this course are to identify common situational causes of nursing concern in palliative care patients describe the prevalence and consequences of provider distress and apply the wounded healer theory to both palliative care providers and the bedside nurse a couple of what my objectives are not so I do not intend that by the end of this you'll be able to recite nice phrases to say to nurses I don't want you to be able to well I do but I don't want you to be able to ease the tension with nurses or explain why you should be nice to nurses a couple of personal disclaimers I am a nurse and a palliative care clinician so over the past months I've had a pretty incredible journey of June 26th of last year I was a bedside nurse on a chaotic general medicine floor and then I took a few days off did my laundry and showed up on July 2nd as a palliative care provider I really did get it again throughout the year I've been struck by the total disconnect between what I thought that palliative care clinicians did and what they actually did I really feel like I had no idea I was also struck by kind of how nursing and palliative medicine are operating in such different silos but caring for the same patient the title of today's presentation is I can't see from here because that's the way that I felt over the past year I felt like when I was a bedside nurse I couldn't really understand the perspective of a palliative care provider and then being a palliative care provider I'm starting to lose the perspective of what it was like to be a bedside nurse and I feel that in both roles I couldn't quite see what everybody did the most shocking thing to me was the realization that some of the cases that have really wounded me as a bedside nurse could have been so easily prevented by providers in an effort to highlight the ways in which these wounds have been impacted on me as a bedside nurse I'm going to talk about three cases today they're not cases that I've talked about publicly or privately for that matter so this is felt like the right time so speaking with you about these cases that help you to gain a different perspective about some of the experiences of bedside nursing and help you see how your impact as a palliative care provider changes that dynamic so we'll start with explaining what the wounded healer theory is so I have chosen these four kind of figures in throughout history to really describe to you how this wounded healer Theory started and then how developed and applied to nursing so we'll start with the legend of Chiron so Chiron was a Greek god he was friends with Hercules however they got in kind of a disagreement one day and Hercule stabbed him with an arrow that was coated in another Greek gods blood so being a great God he's already immortal and now he has these wounds that will never heal because of the coating of the arrows so you have wounds that never heal that are incredibly painful and now you can't die so it's a tough situation for him to be in so he takes himself out of the game and kind of goes into a cave for an extended period of time and the different histories send people to him in order to learn how to seal people and learned his wisdom one of the person one of the people that was sent to him was Escapist you might know him the Greek god of medicine so he taught the great god of medicine about medicine so this is really the first figure that we have that describes this wounded healer then Plato came along and said that the most skilled physicians themselves suffer from every disease and are not by nature very healthy he said that I do not think that they treat the body with the body but rather the body with the soul which cannot treat anything if it is or has been bad in the 1950s the psychologist Carl Jung really applied this to the modern day practitioner so he said that the doctor is effective only when him himself is affected only the wounded physician heals but when the doctor where is his personality like a coat of armor he has no effect for only what he can put right in himself can he hope to put right in the patient and it is his own hurt that gives him the measure of his power to heal so he was really the first one to take this wounded healer concept and apply it to modern medicine then in 2012 Maren Conti O'Hara applied this theory to Nursing in her book the nurse as a wounded healer from trauma to transcendence so she said that caring compassion and empathy are the basic components of Nursing that nursing roots have been wounded by the health care system so I was reading a book on the genesis of nursing and it was talking about how that Mass General started nursing and it was talking about how the nurses here we're kind of the dogs of the hospital and nobody wanted that job so Nursing really started in a place where it wasn't a job that anybody was particularly excited about Florence Nightingale maybe was but so she talks about how there's this path from wounding to trauma to transcendence to then applying those principles to become a healer and she provides many fictional and factual examples of nurses throughout time that have done this so you can see here there are other people you know in literature that do describe this wound healer theory but these are kind of the four that I've chosen to highlight how this theory was started and then how it is applied to nursing so there are some facts about Nursing that as an audience we have to accept as true in order to move forward with this discussion nurses are forced to witness perhaps powerlessly catastrophic events they physically work with the dead so when you start orientation you're taught how to do post-mortem care you're taught how to tie bodies in a way so that they'll stay in the body bags you have to put them in you have to take their clothes off you have to take the Foley out you have to take the drains out you have to do this in a certain way so that the morgue is pleased with you so you learn how to care for dead bodies you then take them down to the morgue eventually the transfer person leaves and you're in this fridge trying to figure out how to log people's names in and then you go back to the floor and you walk into the next room and you have to deal with the woman who's really upset because she got I can't believe it's not butter and not a genuine butter patty no traumatic event is ever wholly overcome by anyone societal recognition of the etiology and long-term effects of Nursing distress and trauma are underdeveloped perhaps because it's insidious subtle and unpalatable even nurses turn away from this topic we are the worst patients with doctors and we don't like to talk about these traumatic events or that they've ever happened when providers are unwell the quality of care is worse we know this as palliative care clinicians we talk a lot about this how we have to be well in order to help others but this is critical in nursing as well because you really can't go into a room and provide compassionate care if there's something stopping you so the first case that I will discuss is a case that occurred in March of 2013 I was working from 7:00 a.m. to 7:00 p.m. and I had a patient she was a 37 year old female she had a history of breast cancer which had been in remission for several years and she came into the IDI with abdominal pain nausea vomiting and back pain she was married and had two young children so she was admitted overnight at 2 o'clock in the morning and told that there was something irregular on her cat skin that needed to be worked up and needed her warranted admission I came in at 7 a.m. and took report on the patient now as part of the nursing role when there's a new AB result and the notification comes up in epic so you actually see it come up every interpretation every lab result every piece of data that's collected by epic Flags and you have to go into the chart and time marks that you've saw it and you acknowledge it and you notified the right people so in that way you're constantly looking at new lab results and it's an expectation of the nursing role that you do that as soon as possible that's why if you've ever covered overnight or any time as a clinician you get so many pages about lab results because that's part of the nursing role so in this way you're continuously looking at results and before I went into the patient and met her that morning I'd already reviewed everything including her cat skin and I knew that she had widely metastatic disease it was everywhere it was in her bones it was in her liver her spine and my recollection was that there weren't very many places it wasn't now I won't boast to be a radiologist or an oncologist but I knew that this was really bad the team wanted to round and collect more data so that they would be able to present her with the whole story that afternoon I took care of her for the next 10 hours helped her eat helped her shower helped her use the bathroom and washed her hair and the whole time she was asking me I don't know why this is taking so long do you know what's happening can you tell me what the test results said do you know when somebody's coming why am I having this pain and the doctors were still compiling data what this what does this do to a person right to have to lie and have to smile and have to provide compassionate care well you know that the person that you're caring for that you're physically touching is ridden with cancer and you know the reason why but you can't say anything I know that you're all thinking oh just go get somebody bring them back and have them come tell her but if we did that for everybody and every new result that came in nothing would get done time is we don't live in a world where time is in surplus knowing the results of a test and having to deny that you know them is something that happens every day to all to nursing and it triggers a sense of anxiety and stress every time so nurses have very high levels of stress they have the highest levels of stress in healthcare it's linked to poor nutrition smoking alcohol and drug abuse they work long hours have disproportionate levels of skill and often working on supported work environments so the American Nurses Association which is kind of the largest body of Nursing did a survey in 2012 and showed that acute on chronic effects of stress were the top health and safety concern for nurses and this data is consistent with that of a survey done in the early 2000 so it really hasn't changed that nurses are ranking this as a top safety concern more shockingly is that 30 to 50 percent of new nurses either change positions or leave Nursing within the first three years I think if you were talking about any field and you were starting out and you were going to school and somebody told you hey but 30 to 50 percent of you guys who are in this class won't actually do this job or will change jobs I think no one here would logically choose that but we do you also have incredibly high rates of anxiety so when study looking at 120 er ICU and general medicine nurses look to use the best anxiety inventory and showed that all scores were in severe range they made highly significant correlations between anxiety rates of depression disassociation and PTSD symptoms the some of the causes for anxiety that these researchers found was frequent traumatic experiences lack of control patience sharing death realizations with the nurse and not their family in order to try to protect the family from what they were realizing an inability to cure interestingly they didn't find that these rates decrease over time at all so it didn't matter if a nurse was there for 30 years or had been in practice for three years the rates of anxiety were the same which really goes to speak to how it doesn't it doesn't like you don't turn seasoned over time you still have this anxiety weather so this brings me to my second case so this was a case that occurred in July of 2017 I was on from 7 p.m. to 7 a.m. and was taking care of a 67 year old female with advanced dermal and systemic sclerosis involving her skin heart multiple organs she also had diabetes and other comorbidities she came into the IDI with shortness of breath and had around a three-week admission for which we were constantly watching the telemetry because she would go by Germany and try Gemini and PVCs and you just sit there and watch it and watch it and watch it and watch it March out overnight I picked her up at 7 p.m. I knew this patient pretty well and I went into a room and stood in the room and was documenting and waiting for her nebulizer to finish in order to give her her nighttime meds I noticed the tele alarm went off and looked up right in time to see her eyes roll back in her head and her body go limp so I yelled for help went and got the backboard started compressions and did 2 cycles before the code team arrived we continued to code this woman as it often happens about 10 minutes and somebody looked up and says anybody called this woman's family so somebody went ran and called the husband who said that they never had a conversation about this so he said we should keep going because they never talked about it he didn't know what she would have wanted so we did for another 30 to 40 minutes to the point where her ribs could be felt to crack and we stop seeing her chest expand in response to the Ambu bag it then became my role to insert needles into her intercostal space to try to re-inflate her lungs four months after this happened I would wake up breathless at night and picture the blood smeared onto my goggles and not be able to take them off I still remember exactly how it felt to push the needle through this woman's sclerotic skin I think that so often in palliative care and in other fields we think that code status is a discussion better left til tomorrow when you've had a really hard goals of care conversation sometimes there's not tomorrow I know that not all of you might agree with code statuses but it doesn't totally matter it's the world that we live in and when some of these eyes are rolling back in their head you don't have enough time to look at their last documented serious illness conversation although maybe someday I know you're working on it so rates of PTSD in nursing are incredibly high so in the community at any given moment the rate is about 3.5% with a 6.8% lifetime prevalence in nursing these two studies looked at adult nurse practitioner adult nurses and pediatric nurses and found that 22 and 21 percent respectively had PTSD symptoms at any given time and 71 and 75 of those experience these symptoms for greater than three months so this just kind of goes to show you it's largely much higher than the general population this is a graph showing the percentage of Hospital providers at risk for PTSD development so they looked at different disciplines within the hospital and you can see that the IDI nurse and ICU nurse and the there's the IDI resident intending also have very high rates of risk and you know what I'm talking about today is nursing but that doesn't mean that it can't be applied to other disciplines there's despite these really high levels of PTSD there is no data on nursing suicide currently so there was multiple studies done one in the 30s to the 50s that said that in Tulsa the top mutated was six times higher than the general population in 1997 a study came out that said that it was in the top five causes of death for female nurses and in the 80s in England and Wales they said that it was an occupational group with the largest proportion of female suicides this was a literature review that was a very robust review and it was published last year and just really goes to show that there there's just no data in this area you can see positions at the top and different public service providers so this brings me to my final case this was in December of 2015 I was working from 7:00 a.m. to 7:00 p.m. that was my third shift in a row and I had a patient he was 98 years old he had advanced dementia hyperlipidemia and hypertension he came into the IDI because his hypertension was very poorly controlled over the three days that I cared for him he became increasingly agitated and aggressive always typically when we were trying to take his blood pressure which as you can imagine we were trying to do quite frequently several times it got so bad that he would run into the hall become physically at risk for himself or others we'd have to call security to come to the floor and we'd take him back into his room and administer I am Haldol it was my job as the nurse to help hold him down and to give the injection on the third day that I had him I did some chart digging and found out that he was a Holocaust survivor and that he had been in an internment camp and had been diagnosed with PTSD in the past this was the reason that he couldn't tolerate ever having his blood pressure taken I've thought about this case and this guy countless times over the past years I'd taken a few days off after this happened and when I came back nobody really knew where he went or what happened I've always assumed he went to one rehab or the other and which is probably true but if anyone said in new they didn't say anything I felt overwhelmingly guilty about this and what I'd done and my acts of physically holding this man down and I still carry a certain amount of moral distress with me we've talked a few times in this ether dome this year and in fellowship about what it means to suffer with and what that does so in nursing that means that to some extent we're simultaneously experiencing the patient suffering from both our own standpoint and from that of a patient it's this phenomenon of suffering with that makes nurses vulnerable I know that in palliative care we do a lot of talking about what it means to sit with suffering and I think that's fabulous but I wonder what the difference is between sitting with suffering and actually physically being the one to hold somebody down and if that's a different degree of suffering with nursing distress has a very long definition it's occupational organizational relational emotional personal moral spiritual and ethical dimensions of stress that interfere with your ability to kick to professionally be responsible so and only do you have this level of distress but you it also impacts the way that you your job is operating everything distress levels are pretty distressing so in 2016 there was a study of 163 oncology nurses you can see here the nurses average square within 8.06 and the patient cut off using this distress thermometer which is the indicator that I used that they use in the study was at 4:00 they would say that they had moderate to severe distress and they would be referred to a mental health provider for increased IVA or for more evaluation so this just goes to show you it's the nursing rates are double yet in 43 percent of the time the nurses didn't report that they had any institutional assistance moral distress decreases quality of care so it decreases the time spent with the patient and the family it's related to job retention and job satisfaction and it's a significant predictor of burnout so in this study they looked at reasons for why nurses left nursing and 25 percent of the time they indicated moral distress as the top reason they'd left their jobs it's cumulative over time it increases while meaning in work decreases the long-term issues similar to anxiety and stress that we looked at before so these things are not going away they don't get better over time it doesn't get easier this is just the definition of moral distress is when one one knows the right action to take but is constricted from doing so so what's happening why are all these things occurring so these are the two the three research studies that have shown that may be indications for why the causes behind PTSD and nursing distress so the first one is experiences leading to PTSD not being able to save the patient's seeing patients die performing medically futile care the next study looking at the reasons for PTSD symptoms to be triggered by the trauma of others were exposure to end-of-life deaths cumulative exposure to patients suffering and then the last one looking at causes of moral distress in the IDI looked at expensive life-saving actions prolonging death not enough information being provided to patients and participating in care of the hopelessly ill patient do you notice anything sounds like so these are our patients right this is our patient population this is who we work with these are these are the people that we're trying to work with going backwards so that brings me to why palliative care why am i discussing this today to this audience I would argue that the impact of palliative care on nursing distress is twofold initially it decreases the opportunity for nursing trauma and secondarily it promotes wounded healers so let's look at number one so decreasing opportunity so I would argue and this is a gross oversimplification of what palliative care is but I would argue that the time.i objective is primarily to decrease patient suffering don't think anybody would have a problem with that but the secondary outcome is that we decrease the amount of events that can trigger nursing distress so these were our patients so if you look at this kind of figure I would argue that we have medical care for those of you across town over here and then we have the patient's goals here without palliative care we're providing a great deal of nursing care that's happening in that space that might not be aligned with the patient's goal so you're doing things like labs procedures holding people down doing CPR that all happens here I think it with palliative care you have that gets shortened there's not as many things that you're providing that happened that are in line with medical goals but not in line with patient's goals I just I think the the number of nursing interventions that you're providing that aren't in line decreases so there's not that much good data on this topic but there is some coming from nurses experiences taking care of patients that are dying so the themes that this these researchers found about end-of-life nursing is that nurses were able to suffer with patients and encounter their true selves they could be authentic forming new attitudes and states of minds consisting of courage calmness and passion it was self illuminating the benefits of end-of-life care were mutual and there's his expressed gratitude for providing this kind of care there's also some literature on hospice nursing that shows that hospice and oncology nurses as years increased they increased self transcendence burnout decreased emotional exhaustion and depolarization decreased and this is directly opposed to all of the data that we saw before on nursing distress and stress so I think that in this population there is possibly something happening we're providing care that's more in line with patient's goals is actually beneficial to nursing so the second one promoting wounded healers so transcendence in this model of the wounded healer is pivotal so without the transcendence and without using the wounds that were inflicted upon you to be able to kind of come to terms with that and then incorporate it into your care you have to find a way to transcend this so I was looking around in the literature about the best way to describe this when it comes to medicine and when it comes to palliative care and with dr. lolis permission I'd like to share a quote from her recent GMO publication it she was discussing her experience with breast cancer and how she was afraid in some way that it would subtract from the care that she was able to provide to her patients and she didn't find that she found that indeed a newfound sense of empathy rather than sympathy now informs her work and strengthens her connection with patients I've noticed one concrete change in my practice in teaching having experienced my fair share of denial I am attuned to its protective power so this just is one example of how somebody was able to use their own experience and it was elevated their practice so what is transcendence look like for bedside nursing it looks like accepting that Nursing is a wounded work force which is kind of a large pill to swallow it means to recognize and heal your own wounds in order to assist others in their own healing it means to place value on the wounds that have been inflicted upon you and it means to expand the concept of PTSD outside of the negative diagnostic label this is reinforced by what we know about nursing so we know that nursing will get there we know that nurses have compassion satisfaction positive feelings derived from helping others through traumatic events we know that the sense of worth is described as one of the most rewarding parts of Nursing and why a lot of nurses do what they do and we know that when you have increased meaning in your work and as a nurse it's protective it protects you against things like burnout and anxiety and distress I think that you'll find this is true for a lot of nurses and for a lot of palliative care providers and for a lot of everybody if you believe in what you're doing and if you want to do it and it changes the way that you work for your lifetime so you might now be asking yourself when do we when are we supposed to do this so this was a figure that was created that shows how nurses can go from a place of possibly PTSD development after a trauma or is go through to the wounded healer down to self healing transformation transcendence and then work the consequence being able to use their therapeutic self so this kind of describes the paths of either PTSD or the wounded healer path I would argue that palliative care impacts this here by as we said before by just decreasing the amount of times that this trauma occurs I also think that it impacts here and here and here and here and here I think that what we do as highlight of care providers and the communication skills that you're already using and the way that you're interacting with the patients and the staff is already impacting the development of this pathway I can say that because it's happened to me so in conclusion I hope that you understand that palliative care is already doing this work I think that's so often we learn about things that will promote us to do things better or do things differently or have a change in our practice and I want you to know that I think that this is something that palliative care is already providing I hope that you have different implications on your practice and what the implications are of what you do as a palliative care provider I hope that you can consider palliative care is impact on a larger scale outside of just the relationship with the patient the relationship with your colleagues I hope that you can consider this your relationship with the patient and the nurse and the healthcare system as a whole and how what happens to that system I hope that you can let this add value to the work that you do I hope that you can promote nursing as wounded healers I have been incredibly lucky over this past year to have worked with some amazing mentors and cofell OHS and everybody that I've worked with that's helped me to take the wounds that have been inflicted on me and to turn them into things that are an asset to my practice and I thank you all for that the end I guess now we do questions Thank You Kate I have to do anything no repeat oh thank you very much Kate Sharon Levine from geriatrics your third cases our lives all the time so this this begs a question in in in education for medical students and often in residency programs there are reflection rounds to help people to deal with these kinds of things I mean one of the things that you talked about which is really very true was that I love I'm one of the reasons I'm a geriatrician is because I love my interprofessional colleagues especially nurses and how much muck and fluid and everything they deal with is really sort of amazing to me but I wonder if this has been incorporated the reflection and talking about this into nursing education either at the basic level or at advanced practice level so I can speak to my own experience so everybody heard it I think it was incorporated at the very start but I wasn't in the weeds enough to know why was being taught it so I think that it does get wrapped into nursing school but it's just too early for nurses to really kind of accept like know what's happening enough like we had a mindfulness class I was like oh this is great like but I didn't know why I was needed to be mindful you know so I think it kind of is something that needs to be incorporated later in nursing practice instead of in school although probably valuable in educational programs as well Kate that was amazing I just thought of an image as you were talking about the wounded healer in Japanese culture when I when pottery breaks often they fill the scars in with gold and it's and instead of thinking about how we all have scars and sort of to celebrate them and I sort of think of that image as the new form of beauty that that we in our nursing careers have you know been able to establish so it was beautiful thank you thank you Kate that was really fantastic I one of the things that struck me when I was looking at prognostic models and heart failure is when you come up with computer models computer models are better than physicians and predicting prognosis but they're not better than nurses bedside nurse predicting prognosis and it made me think about all the things that a bedside nurse sees during a day that helps them to formulate some kind of prognostic picture and made me wonder about our training and they wonder if you can speak to having been in an interprofessional fellowship are there things that you think if other other residences and fellowships were interprofessional ways that this might be better yeah I mean I've learned a lot from being in this propeller ship and being with physicians and at the same time and I will infer on them that they've learned a lot from being with me I can say that I do think like I think you can't understand a different role until you have somebody that you're close with that's done that role and I I don't know about how the easiest way to to do that is but I think just spending time with people and just listening to different people's perspectives is the most important thing I when we when I was a nurse we had medical students shadow us for the day so as part of the teaching program they came with us and were with us for 12 hours and they were always like by the end of the day like and I I knew that it impacted them in a way so I think if something like that like some model like that where you get to actually see the role is like would go a long ways I have a question wonderful job Kate you said that this is one of the objectives is not to learn how about nice things to say to nurses I wouldn't discourage people from doing that I would however I wonder if there's a way that we as palliative care providers can tune into the wounds that may be in the process of forming and if there's a way to kind of I guess take it get a sense of that when we're talking to nurse at the bedside yeah I think that my hope for this talk and where I said not to recite phrases is that I hope that you get a different perspective for why somebody might run down the hall and say did you talk about code status they can't be a full code like and I know it's probably the care providers were like oh my god I know like but like there that's coming from somewhere right so I would just encourage everybody to know that the nurse might be in somewhere someplace in that pathway from trauma to kind of use being a wounded healer and you never know where somebody's at when you're talking with them and I think a lot of what we learned as part of care providers and the communication skills that it's ingrained and I I think just using those skills to talk with the nurses as well any other questions here thanks Kate that was awesome I'm thinking about your title and intro when you said I cannot see from here and how when you were a nurse you couldn't truly picture what it would be like to be a palliative care provider and now vice versa as a palliative care provider it's getting harder to hold on to those things that made you a nurse how do you anticipate kind of maintaining that nursing identity going forward and I guess where do you stand can you see now from here I think I can see now a little bit more as most of you know I've still been working as a bedside nurse at the Brigham for four shifts a month so I kind of used that to ground myself back in it I don't know if I stopped doing that how I will keep that I think it's just remembering the cases that I've had and trying to remind myself of that perspective but this heart and as you move into a different role and I think at the start of fellowship I really thought like okay I had to like push that aside and that was like not my job anymore and now I have to do this job and learning how to kind of incorporate those two things I don't know in a good way too though okay that was a fabulous talk and having been a nurse for Oh greater than 30 years and a palliative care nurse practitioner for over a dozen years you stirred up a lot of stuff that like you said people don't talk about it when you started you had said something about silos and I think I'm Kathleen kind of addressed that a little bit in the interdisciplinary I just just wondering how you what you envision in your day-to-day palliative care because this is something that I personally feel that physicians have a perspective nurses have a perspective and that we should truly be a team because we have different perspectives and different experiences and different education do you have any common yeah I mean I think a lot of times unfortunately it comes down to time and when you're in the hospital it's like you have to go see the next person and you don't communicate as well as like one should and I don't want to stand up here and say you should always contact to the nurses but so uh like I think that is the answer right like I don't think it's any more complicated I think it's that 30 seconds after the family meeting that you go back and say what happened in the family meeting that that impacts things I think I when I talked before I didn't when I was a bedside nurse I didn't know that physicians emailed about patients I like had no idea that was a thing so there was all this build-up to family meetings and I would just come in every day and be like I can't believe nobody's doing anything about this and then on the third day somebody would be like oh we've been emailing for two weeks about this and I'd be like was I supposed to like so you have this moral distress that builds and builds and builds and you just don't know that other people are communicating about it as well so I do actually think that the solution is just as simple as communicating which is frustrating and easy answer thank you any questions from Dana Farber hello any other questions all right thank you thank you so much

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