Adult Surviving Sepis Campaign Guidelines (Hour-1 Bundle)
Children's Surviving Sepsis Campaign Guidelines
Adult ICU Liberation Guidelines and Bundle (A-F)
Management of Adults with COVID-19
New User? Sign Up Free
SCCM is updating its SCCM Connect Community. Access to SCCM Connect may be limited until April 23.
Michael D. Williams, MD, FACS; Mary Faith Marshall, PhD, FCCM
A 76-year-old woman is admitted to the surgical intensive care unit (ICU) after surgery for a ruptured abdominal aortic aneurysm. She is in shock and on vasopressors for the first 24 hours of her stay. Over time she recovers and is successfully weaned from mechanical ventilation and extubated. At the time of her extubation, the nurse caring for her is a first-generation immigrant from sub-Saharan Africa. Among the first words that the patient speaks after her endotracheal tube is removed are: “I don’t want that ‘N-word’ anywhere near me.” When examined further, she is found to be alert and completely oriented. She simply has a strong bias against black people.
“There’s something wrong when a person can go to work, be subject to intolerance or abuse, and have it be ignored and accepted by colleagues as part of the job.”1
Racial discrimination at the bedside is not new. In a 2012 law review article, Paul-Emile Kimani noted: “When we think of race discrimination in healthcare today, we tend to think about race-based health disparities and bias exhibited by physicians or other providers, but new studies illuminate a different kind of race discrimination in the hospital setting. Today, rather than turning patients away based on race, healthcare providers are instead facilitating patients’ racial biases by enabling them to turn physicians away based on race. In other words, healthcare providers accommodate patients’ racial preferences.”2
Accommodation of patients’ racial (or other demographic) requests for provider type has been shown to have positive health effects. But such accommodations also violate principles such as respect for persons and justice that underlie antidiscrimination and federal and state civil rights laws, and perpetuate intolerance and racial inequality. There have been several lawsuits by clinical staff against medical centers in cases of accommodation of racial requests.
Our medical center has seen a recent and unfortunate trend among patients and visitors who seem emboldened by the current sociopolitical climate to freely exhibit their prejudices. Such behaviors at the bedside demonstrate a more widespread social phenomenon. The Ku Klux Klan has rallied several times in our community to protest the removal of a Confederate statue. Neighborhoods have been blanketed with flyers alleging genocidal campaigns to “erase white people from the face of the earth.” Gregory Townsend, MD, School of Medicine Associate Dean for Diversity, laments, “I have lived here for most of the last 35 years, going back to when I was a med student here. My wife found these in our driveway Monday—the first time that we have experienced anything like this. I’m assuming that we weren’t specifically targeted but were just part of a blanket ‘outreach’ in our (mostly white) neighborhood. What is going on?”
We are not alone in this upsurge of discrimination and hostility. A recent New England Journal of Medicine article addressed an increase in the United States of racial hostility and political polarization and, in particular, examined the role that the recent presidential election has played in surfacing preexisting racial and other discriminatory animus.3 More than half of the respondents to a survey of K-12 teachers revealed that “since the 2016 presidential campaign began, many of their students have been ‘emboldened’ to use slurs and name calling and to say bigoted and hostile things about minorities, immigrants, and Muslims.”4
Research shows adverse physical and mental health effects of racial discrimination on individuals and communities, including epigenetic patterns of aging, elevated risk of death, and adverse health effects not only through particular experiences of discrimination, but also through rumination, vigilance, and worry over potential exposures.3
Case Study Analysis
Patients are neither legally nor ethically entitled to the provision of care by a clinician of a certain demographic profile (e.g., age, race, gender, sexual orientation, or religious affiliation). Patients have the right to refuse treatment from a clinician who does not meet a certain demographic profile and are entitled to choose another venue for their healthcare. This is not so easily done when a patient is in extremis in the emergency department or the ICU.
Using a framework that includes assessing patient acuity (we would add decisional capacity), cultivating a therapeutic alliance, depersonalizing the event, and ensuring a safe learning environment, Whitgob et al have developed response strategies for discrimination against trainees that include faculty and trainee development, frontline faculty interventions, and institutional preparedness and response.5
Our academic health center has implemented a comprehensive plan to address discrimination of any kind in the workplace. A multidisciplinary task force comprising students, faculty, staff, academic deans, and medical center administrators developed and implemented the following strategies with the goal of demonstrating our commitment to inclusion and diversity versus simply telling others about it.