Affiliations: Wayne State University, Detroit, MI,
Johns Hopkins University, Baltimore, MD
Correspondence to: Hari K. Dandapantula, MD, Wayne State University, 550 E Canfield, Detroit, MI 48201; e-mail: email@example.com
We read the editorial by Wu et al1(November 2006) with a lot of enthusiasm but were surprised by the not so well founded and contradictory statements in the article. It was stated in the first paragraph that “ICUs are dangerous places” and that “ … no sane person would place themselves so squarely in harm’s way”; while, in fact, ICUs are the safest places to treat sick patients, with an ideal nurse-to-patient ratio, supervised by well-trained and dedicated staff and consultants with quick availability of laboratory results and medications. Resource availability and care are better in the ICU than at any other place in any given hospital.2–3
Looking at it from any angle, we could not agree with the authors on the above two statements. Errors in the hospital in general and ICUs in particular are cited as reasons for the above statements, but as is well known, ICUs have come a long way from where we started.2–4 We strongly believe that perfection is a “way” and not a “destination,” and quality improvement and error prevention is a continuous process and not a one-stop goal.
It was also suggested that to ensure patient-focused care in ICU, it is good to think that “I have only three patients… One is my parent, one is my spouse, and one is my child.” This statement has no medical ethical basis, as it promotes a lot of conflict in patient care. What patients and their families expect from a doctor is not another family member but a good doctor.5Physicians are advised to perform their jobs by being nonjudgmental, refraining from emotional attachment with the patients and their families while responding to patient and family needs with empathy and with the best of the best deliverable care.6The suggestions of the authors were contradictory, as these suggestions were promoting paternalism while asking for partnership with patients.7–8
The authors have no conflicts of interest to disclose.
Drs. Wu and Sexton have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Dr. Pronovost is a stockholdeer in VISICU, Inc.
We appreciate the interest shown by Drs. Dandapantula and Katkuri in our editorial in a recent issue of CHEST (November 2006)1 entitled “Partnership With Patients: A Prescription for ICU Safety.” But, we disagree with their notions about the safety of ICUs, medical ethics, and the role of emotion in medicine.
ICUs can be an effective place to deliver specific therapies, and they are organized to allow close monitoring. However, this does not mean that they are safe. Numerous studies2 have shown that, despite potential benefits, many patients are harmed in the ICU. Having more nurses may allow for the closer observation of patients but also may increase risk because each patient is subjected to more interventions.
Traditionally, ICUs have emphasized technical goals and efficiency rather than safety. Many procedures are still conducted without the benefit of basic error prevention, including the placement and removal of central lines, and the use of arterial lines, intracranial pressure monitoring, and pulmonary artery catheters. All of these frequently cause harm.3–5 Advances in technology must be coupled with evaluations, so that technology and procedures are used safely, and only in patients who will benefit.
Our recommendation to think of patients as family members has nothing to do with paternalism but is rooted in the core precept of medical ethics to balance benefits and harm.6We reject the notion that physicians should refrain from emotion when dealing with their patients. Patients want physicians who are caring as well as competent.7Indeed, there is a correlation between positive affect and treating patients with greater respect.8At our own institution, the breakthrough that allowed us to move toward a culture of safety was sharing with practitioners the pain of a mother whose toddler had died from medical errors.9 This gave our staff an emotional commitment to improving safety.
Care should be both effective and safe. Treating patients with the same respect and regard that we have for family members can motivate greater awareness of the potential risks of treatment and greater personal responsibility for improving safety.
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