Hospital Medicine

The police shooting of Jacob Blake, an unarmed Wisconsin man, during an arrest in August 2020, led to more protests in a summer filled with calls against the unequal application of police force. Outrage grew as it was revealed that Blake, paralyzed from his waist down and not yet convicted of a crime, was still handcuffed to his hospital bed while receiving treatment.¹ To many this seemed unusually cruel, but to those tasked with caring for incarcerated patients, it is all too familiar. Given the high rates of incarceration in the United States and the increased medical needs of this population, caring for those in custody is unavoidable for many physicians and hospitals. Though safety should be paramount, the universal application of metal handcuffs or leg cuffs by law enforcement officials, a process known as shackling, can lead to a variety of harms and should be abandoned.

The United States incarcerates more individuals both in total numbers and per capita than any other country in the world. This is currently believed to be more than two million people on any given day or more than 650 persons per 100,000 population.² Incarceration occurs in jails, which are locally run facilities holding individuals on short sentences or those not yet convicted who are unable to afford bail before their trials (pretrial), or prisons, which are state and federally run facilities that house those with long sentences. When an incarcerated person experiences a medical emergency requiring hospitalization, they are either treated in the correctional facility or transferred to a local hospital for a higher level of care. Some hospitals are equipped with security measures similar to those of a correctional facility, with secure floors or wings dedicated solely to the care of the incarcerated. Secure units are more commonly seen in hospitals associated with prisons rather than local jails. Other hospitals house incarcerated patients in the same rooms as the public population, and thus movement is restricted by other means.³ Most commonly, this is done with a hard metal shackle resembling a handcuff with one end attached to the leg or wrist and the other end attached to the bed. Some agencies require more restraints, often requiring the use of wrist cuffs and leg cuffs concurrently for the entire duration of a patient’s hospitalization.⁴ In our experience, agencies apply these restraints universally, regardless of age, illness, mobility, or pretrial status.

Restraint practices are rooted in a concern for practitioner and public safety and bear merit. A patient from a correctional facility is usually guarded by just one officer in lieu of the multiple security measures at a jail or prison facility. Nonsecured hospitals have become sites of multiple escapes by incarcerated inpatients, given the lack of secured doors and the multiple movements during the admission and discharge processes.⁵ Furthermore, violence against hospital staff is now a focus issue in many hospitals and is no longer accepted as just “part of the job.” In several high-profile incidents, incarcerated inpatients have harmed staff, including one at our own institution, when an incarcerated patient held a makeshift weapon to a student’s throat.⁶

The use of shackles during hospital visits has been challenged in US courts and routinely upheld. In one case, an incarcerated patient with renal failure received injuries after his leg edema was so severe that “at one point the shackles themselves were barely visible.”⁷ Though he was injured, the shackles were determined to have served a penological purpose outside of punishment, such as preventing escape, and the injuries were the result of the patient’s guards not following protocol. British courts have taken a different stance, ruling for an incarcerated patient who challenged the use of cuffs during three outpatient appointments and one inpatient admission.⁸ While the cuffs in the outpatient setting were deemed acceptable (as they were removed during the medical visit itself), they remained during the duration of the inpatient stay. This was deemed in violation of Title I/Article 3 of the Charter of Fundamental Rights of the European Union, Dignity/The right to integrity of the person. One area in US healthcare where shackling has been roundly condemned is the peripartum shackling of pregnant women. Though courts have had a mixed record to challenges, activism and advocacy have led to the banning of the practice in 23 states, though in most states significant exemptions exist.⁹ Through the First Step Act of 2018, the federal government banned peripartum shackling for all federal prisoners, but as most incarcerations are under state or local control, a considerable number of incarcerated pregnant women can legally be shackled during their deliveries.

Legal and safety concerns aside, the shackling of incarcerated patients carries enormous risk. The use of medical restraints in hospitals has decreased over the past few decades, given their proven harms in increasing falls, exacerbating delirium, and increasing the risk of in-hospital death.¹⁰ There is no reason to believe that trading a soft medical restraint for a metal leg or wrist cuff would not confer the same risk. Additionally, metal law enforcement cuffs are not designed with patient safety in mind and have been known to cause specific nerve injuries, or handcuff neuropathy. This can occur when placement is too tight or when a patient struggles against them, as could happen with an agitated or delirious patient. The bar for removal, even briefly for an exam, is also much higher than that of a medical restraint, leading to a greater likelihood that certain aspects of the physical exam, such as gait or strength assessment, may not be adequately performed. In one small survey, British physicians reported often performing an exam while the patient was cuffed and with a guard in the room, despite country guidelines against both practices.¹¹

Additionally, marginalized communities are disproportionately incarcerated and have a fraught and tenuous relationship with the healthcare system. Black patients routinely report greater mistrust than White patients in the outcomes of care and the motivations of physicians, in large part due to past and current discrimination and the medical community’s history of experimentation.¹² A shackled patient may view a treating physician and hospital as complicit with the practice, rather than seeing the practice as something outside of their control. If a patient’s sole interaction with inpatient medicine involves shackling, it risks damaging whatever fragile physician-patient relationship may exist and could delay or limit care even further.

While the universal application of metal handcuffs or leg cuffs ensures low rates of escape or attacks on workers, it does so at the expense of vulnerable individuals. We have cared for an incarcerated elderly woman arrested for multiple traffic violations, a man with severe autism who slipped through the cracks of mental health diversion protocols and ended up in jail, and an arrested delirious man with severe alcohol withdrawal, all shackled with hard shackles on the wrists, legs, or in the final case, both. Safety and the rights of the vulnerable are not mutually exclusive, and we feel the following measures can protect both.

First, the universal application of shackles in the hospitalized incarcerated patient should end. If no alternative security measures are available for high-risk patients, correctional facilities must document their necessity as physicians and nurses are required to do for medical restraints. Hospitals should have processes in place for providers who feel unsafe with an unshackled patient or think a patient is unnecessarily shackled, and collegial discussions about shackling with law enforcement should be the norm. If safe to do so, shackles should routinely be removed for physical exams without question. Since law enforcement officials, rather than the hospitals, make the rules for shackling, this will take some degree of physician and administrative advocacy at the hospital level and legislative advocacy at the local and state levels.

Second, vulnerable populations, such as the elderly, those experiencing a mental health crisis, or others at risk for in-hospital delirium, should never be restrained with hard law enforcement cuffs. Restraint procedures should follow standard medical restraint procedures, and soft restraints should be used if at all possible. Given the high rates of psychiatric illness amongst the incarcerated and the role jails play in filling gaps in psychiatric care, medical admissions for those with mental illness are not rare occasions.

Finally, hospitals routinely taking care of an incarcerated population should seek to build secure units, a move that would dramatically reduce the need for shackling. In several cities, the primary referral hospitals for some of the largest jails in the country do not have units with the proper security to allow for freedom of movement, and thus, shackling persists. Creating secure units will take significant investment on the part of hospital and local authorities, but there is potential for decreasing costs due to consolidating supervision, which would lead to better patient outcomes given the above risks.

Advocating for the health of the incarcerated, even those who have not yet been convicted, is typically not a high priority for the general public. As inpatient physicians, we see the impact universal shackling has on some of our most vulnerable patients and should be their voice where they have none. Advocating for and implementing the above procedures will be a step toward improving patient care while maintaining safety.

The police shooting of Jacob Blake, an unarmed Wisconsin man, during an arrest in August 2020, led to more protests in a summer filled with calls against the unequal application of police force. Outrage grew as it was revealed that Blake, paralyzed from his waist down and not yet convicted of a crime, was still handcuffed to his hospital bed while receiving treatment.¹ To many this seemed unusually cruel, but to those tasked with caring for incarcerated patients, it is all too familiar. Given the high rates of incarceration in the United States and the increased medical needs of this population, caring for those in custody is unavoidable for many physicians and hospitals. Though safety should be paramount, the universal application of metal handcuffs or leg cuffs by law enforcement officials, a process known as shackling, can lead to a variety of harms and should be abandoned.

The United States incarcerates more individuals both in total numbers and per capita than any other country in the world. This is currently believed to be more than two million people on any given day or more than 650 persons per 100,000 population.² Incarceration occurs in jails, which are locally run facilities holding individuals on short sentences or those not yet convicted who are unable to afford bail before their trials (pretrial), or prisons, which are state and federally run facilities that house those with long sentences. When an incarcerated person experiences a medical emergency requiring hospitalization, they are either treated in the correctional facility or transferred to a local hospital for a higher level of care. Some hospitals are equipped with security measures similar to those of a correctional facility, with secure floors or wings dedicated solely to the care of the incarcerated. Secure units are more commonly seen in hospitals associated with prisons rather than local jails. Other hospitals house incarcerated patients in the same rooms as the public population, and thus movement is restricted by other means.³ Most commonly, this is done with a hard metal shackle resembling a handcuff with one end attached to the leg or wrist and the other end attached to the bed. Some agencies require more restraints, often requiring the use of wrist cuffs and leg cuffs concurrently for the entire duration of a patient’s hospitalization.⁴ In our experience, agencies apply these restraints universally, regardless of age, illness, mobility, or pretrial status.

Restraint practices are rooted in a concern for practitioner and public safety and bear merit. A patient from a correctional facility is usually guarded by just one officer in lieu of the multiple security measures at a jail or prison facility. Nonsecured hospitals have become sites of multiple escapes by incarcerated inpatients, given the lack of secured doors and the multiple movements during the admission and discharge processes.⁵ Furthermore, violence against hospital staff is now a focus issue in many hospitals and is no longer accepted as just “part of the job.” In several high-profile incidents, incarcerated inpatients have harmed staff, including one at our own institution, when an incarcerated patient held a makeshift weapon to a student’s throat.⁶

The use of shackles during hospital visits has been challenged in US courts and routinely upheld. In one case, an incarcerated patient with renal failure received injuries after his leg edema was so severe that “at one point the shackles themselves were barely visible.”⁷ Though he was injured, the shackles were determined to have served a penological purpose outside of punishment, such as preventing escape, and the injuries were the result of the patient’s guards not following protocol. British courts have taken a different stance, ruling for an incarcerated patient who challenged the use of cuffs during three outpatient appointments and one inpatient admission.⁸ While the cuffs in the outpatient setting were deemed acceptable (as they were removed during the medical visit itself), they remained during the duration of the inpatient stay. This was deemed in violation of Title I/Article 3 of the Charter of Fundamental Rights of the European Union, Dignity/The right to integrity of the person. One area in US healthcare where shackling has been roundly condemned is the peripartum shackling of pregnant women. Though courts have had a mixed record to challenges, activism and advocacy have led to the banning of the practice in 23 states, though in most states significant exemptions exist.⁹ Through the First Step Act of 2018, the federal government banned peripartum shackling for all federal prisoners, but as most incarcerations are under state or local control, a considerable number of incarcerated pregnant women can legally be shackled during their deliveries.

Legal and safety concerns aside, the shackling of incarcerated patients carries enormous risk. The use of medical restraints in hospitals has decreased over the past few decades, given their proven harms in increasing falls, exacerbating delirium, and increasing the risk of in-hospital death.¹⁰ There is no reason to believe that trading a soft medical restraint for a metal leg or wrist cuff would not confer the same risk. Additionally, metal law enforcement cuffs are not designed with patient safety in mind and have been known to cause specific nerve injuries, or handcuff neuropathy. This can occur when placement is too tight or when a patient struggles against them, as could happen with an agitated or delirious patient. The bar for removal, even briefly for an exam, is also much higher than that of a medical restraint, leading to a greater likelihood that certain aspects of the physical exam, such as gait or strength assessment, may not be adequately performed. In one small survey, British physicians reported often performing an exam while the patient was cuffed and with a guard in the room, despite country guidelines against both practices.¹¹

Additionally, marginalized communities are disproportionately incarcerated and have a fraught and tenuous relationship with the healthcare system. Black patients routinely report greater mistrust than White patients in the outcomes of care and the motivations of physicians, in large part due to past and current discrimination and the medical community’s history of experimentation.¹² A shackled patient may view a treating physician and hospital as complicit with the practice, rather than seeing the practice as something outside of their control. If a patient’s sole interaction with inpatient medicine involves shackling, it risks damaging whatever fragile physician-patient relationship may exist and could delay or limit care even further.

While the universal application of metal handcuffs or leg cuffs ensures low rates of escape or attacks on workers, it does so at the expense of vulnerable individuals. We have cared for an incarcerated elderly woman arrested for multiple traffic violations, a man with severe autism who slipped through the cracks of mental health diversion protocols and ended up in jail, and an arrested delirious man with severe alcohol withdrawal, all shackled with hard shackles on the wrists, legs, or in the final case, both. Safety and the rights of the vulnerable are not mutually exclusive, and we feel the following measures can protect both.

First, the universal application of shackles in the hospitalized incarcerated patient should end. If no alternative security measures are available for high-risk patients, correctional facilities must document their necessity as physicians and nurses are required to do for medical restraints. Hospitals should have processes in place for providers who feel unsafe with an unshackled patient or think a patient is unnecessarily shackled, and collegial discussions about shackling with law enforcement should be the norm. If safe to do so, shackles should routinely be removed for physical exams without question. Since law enforcement officials, rather than the hospitals, make the rules for shackling, this will take some degree of physician and administrative advocacy at the hospital level and legislative advocacy at the local and state levels.

Second, vulnerable populations, such as the elderly, those experiencing a mental health crisis, or others at risk for in-hospital delirium, should never be restrained with hard law enforcement cuffs. Restraint procedures should follow standard medical restraint procedures, and soft restraints should be used if at all possible. Given the high rates of psychiatric illness amongst the incarcerated and the role jails play in filling gaps in psychiatric care, medical admissions for those with mental illness are not rare occasions.

Finally, hospitals routinely taking care of an incarcerated population should seek to build secure units, a move that would dramatically reduce the need for shackling. In several cities, the primary referral hospitals for some of the largest jails in the country do not have units with the proper security to allow for freedom of movement, and thus, shackling persists. Creating secure units will take significant investment on the part of hospital and local authorities, but there is potential for decreasing costs due to consolidating supervision, which would lead to better patient outcomes given the above risks.

Advocating for the health of the incarcerated, even those who have not yet been convicted, is typically not a high priority for the general public. As inpatient physicians, we see the impact universal shackling has on some of our most vulnerable patients and should be their voice where they have none. Advocating for and implementing the above procedures will be a step toward improving patient care while maintaining safety.

The police shooting of Jacob Blake, an unarmed Wisconsin man, during an arrest in August 2020, led to more protests in a summer filled with calls against the unequal application of police force. Outrage grew as it was revealed that Blake, paralyzed from his waist down and not yet convicted of a crime, was still handcuffed to his hospital bed while receiving treatment.¹ To many this seemed unusually cruel, but to those tasked with caring for incarcerated patients, it is all too familiar. Given the high rates of incarceration in the United States and the increased medical needs of this population, caring for those in custody is unavoidable for many physicians and hospitals. Though safety should be paramount, the universal application of metal handcuffs or leg cuffs by law enforcement officials, a process known as shackling, can lead to a variety of harms and should be abandoned.

The United States incarcerates more individuals both in total numbers and per capita than any other country in the world. This is currently believed to be more than two million people on any given day or more than 650 persons per 100,000 population.² Incarceration occurs in jails, which are locally run facilities holding individuals on short sentences or those not yet convicted who are unable to afford bail before their trials (pretrial), or prisons, which are state and federally run facilities that house those with long sentences. When an incarcerated person experiences a medical emergency requiring hospitalization, they are either treated in the correctional facility or transferred to a local hospital for a higher level of care. Some hospitals are equipped with security measures similar to those of a correctional facility, with secure floors or wings dedicated solely to the care of the incarcerated. Secure units are more commonly seen in hospitals associated with prisons rather than local jails. Other hospitals house incarcerated patients in the same rooms as the public population, and thus movement is restricted by other means.³ Most commonly, this is done with a hard metal shackle resembling a handcuff with one end attached to the leg or wrist and the other end attached to the bed. Some agencies require more restraints, often requiring the use of wrist cuffs and leg cuffs concurrently for the entire duration of a patient’s hospitalization.⁴ In our experience, agencies apply these restraints universally, regardless of age, illness, mobility, or pretrial status.

Restraint practices are rooted in a concern for practitioner and public safety and bear merit. A patient from a correctional facility is usually guarded by just one officer in lieu of the multiple security measures at a jail or prison facility. Nonsecured hospitals have become sites of multiple escapes by incarcerated inpatients, given the lack of secured doors and the multiple movements during the admission and discharge processes.⁵ Furthermore, violence against hospital staff is now a focus issue in many hospitals and is no longer accepted as just “part of the job.” In several high-profile incidents, incarcerated inpatients have harmed staff, including one at our own institution, when an incarcerated patient held a makeshift weapon to a student’s throat.⁶

The use of shackles during hospital visits has been challenged in US courts and routinely upheld. In one case, an incarcerated patient with renal failure received injuries after his leg edema was so severe that “at one point the shackles themselves were barely visible.”⁷ Though he was injured, the shackles were determined to have served a penological purpose outside of punishment, such as preventing escape, and the injuries were the result of the patient’s guards not following protocol. British courts have taken a different stance, ruling for an incarcerated patient who challenged the use of cuffs during three outpatient appointments and one inpatient admission.⁸ While the cuffs in the outpatient setting were deemed acceptable (as they were removed during the medical visit itself), they remained during the duration of the inpatient stay. This was deemed in violation of Title I/Article 3 of the Charter of Fundamental Rights of the European Union, Dignity/The right to integrity of the person. One area in US healthcare where shackling has been roundly condemned is the peripartum shackling of pregnant women. Though courts have had a mixed record to challenges, activism and advocacy have led to the banning of the practice in 23 states, though in most states significant exemptions exist.⁹ Through the First Step Act of 2018, the federal government banned peripartum shackling for all federal prisoners, but as most incarcerations are under state or local control, a considerable number of incarcerated pregnant women can legally be shackled during their deliveries.

Legal and safety concerns aside, the shackling of incarcerated patients carries enormous risk. The use of medical restraints in hospitals has decreased over the past few decades, given their proven harms in increasing falls, exacerbating delirium, and increasing the risk of in-hospital death.¹⁰ There is no reason to believe that trading a soft medical restraint for a metal leg or wrist cuff would not confer the same risk. Additionally, metal law enforcement cuffs are not designed with patient safety in mind and have been known to cause specific nerve injuries, or handcuff neuropathy. This can occur when placement is too tight or when a patient struggles against them, as could happen with an agitated or delirious patient. The bar for removal, even briefly for an exam, is also much higher than that of a medical restraint, leading to a greater likelihood that certain aspects of the physical exam, such as gait or strength assessment, may not be adequately performed. In one small survey, British physicians reported often performing an exam while the patient was cuffed and with a guard in the room, despite country guidelines against both practices.¹¹

Additionally, marginalized communities are disproportionately incarcerated and have a fraught and tenuous relationship with the healthcare system. Black patients routinely report greater mistrust than White patients in the outcomes of care and the motivations of physicians, in large part due to past and current discrimination and the medical community’s history of experimentation.¹² A shackled patient may view a treating physician and hospital as complicit with the practice, rather than seeing the practice as something outside of their control. If a patient’s sole interaction with inpatient medicine involves shackling, it risks damaging whatever fragile physician-patient relationship may exist and could delay or limit care even further.

While the universal application of metal handcuffs or leg cuffs ensures low rates of escape or attacks on workers, it does so at the expense of vulnerable individuals. We have cared for an incarcerated elderly woman arrested for multiple traffic violations, a man with severe autism who slipped through the cracks of mental health diversion protocols and ended up in jail, and an arrested delirious man with severe alcohol withdrawal, all shackled with hard shackles on the wrists, legs, or in the final case, both. Safety and the rights of the vulnerable are not mutually exclusive, and we feel the following measures can protect both.

First, the universal application of shackles in the hospitalized incarcerated patient should end. If no alternative security measures are available for high-risk patients, correctional facilities must document their necessity as physicians and nurses are required to do for medical restraints. Hospitals should have processes in place for providers who feel unsafe with an unshackled patient or think a patient is unnecessarily shackled, and collegial discussions about shackling with law enforcement should be the norm. If safe to do so, shackles should routinely be removed for physical exams without question. Since law enforcement officials, rather than the hospitals, make the rules for shackling, this will take some degree of physician and administrative advocacy at the hospital level and legislative advocacy at the local and state levels.

Second, vulnerable populations, such as the elderly, those experiencing a mental health crisis, or others at risk for in-hospital delirium, should never be restrained with hard law enforcement cuffs. Restraint procedures should follow standard medical restraint procedures, and soft restraints should be used if at all possible. Given the high rates of psychiatric illness amongst the incarcerated and the role jails play in filling gaps in psychiatric care, medical admissions for those with mental illness are not rare occasions.

Finally, hospitals routinely taking care of an incarcerated population should seek to build secure units, a move that would dramatically reduce the need for shackling. In several cities, the primary referral hospitals for some of the largest jails in the country do not have units with the proper security to allow for freedom of movement, and thus, shackling persists. Creating secure units will take significant investment on the part of hospital and local authorities, but there is potential for decreasing costs due to consolidating supervision, which would lead to better patient outcomes given the above risks.

Advocating for the health of the incarcerated, even those who have not yet been convicted, is typically not a high priority for the general public. As inpatient physicians, we see the impact universal shackling has on some of our most vulnerable patients and should be their voice where they have none. Advocating for and implementing the above procedures will be a step toward improving patient care while maintaining safety.

An 88-year-old male veteran with a medical history of chronic obstructive pulmonary disease (COPD) on home oxygen, chronic alcohol use, squamous cell carcinoma of the lung status after left upper lobectomy, and a 5.7 cm thoracic aortic aneurysm was admitted to the inpatient medical service for progressive dyspnea and productive cough. The patient was in his usual state of health until 2 days before presentation. A chest computed tomography scan showed a right lower lobe infiltrate, concerning for pneumonia, and stable thoracic aortic aneurysm (Figure). On admission, the patient was started on IV ceftriaxone 2 g daily for pneumonia and nebulizer therapy of combined albuterol 15 mg and ipratropium 1,500 mg every 6 hours for symptomatic treatment of his dyspnea.

The patient responded well to therapy, and his cough and dyspnea improved. However, 72 hours after admission, he developed an asymptomatic acute kidney injury (AKI) and anion-gap metabolic acidosis. His serum creatinine increased from baseline 0.6 mg/dL to 1.2 mg/dL. He also had an anion gap of 21 mmol/L and a decrease in bicarbonate from 23 mmol/L to 17 mmol/L. His condition was further complicated by new-onset hypertension (153/111 mm Hg). His calculated fractional excretion of sodium (FENa) was 0.5%, and his lactate level returned elevated at 3.6 mmol/L. On further investigation, he reported alcohol use the night prior; however, his β-hydroxybutyrate was negative, and serum alcohol level was undetectable. Meanwhile, the patient continued to receive antibiotics and scheduled nebulizer treatments. Although his AKI resolved with initial fluid resuscitation, his repeat lactate levels continued to trend upward to a peak of 4.0 mmol/L.

• What is your diagnosis?
• How would you treat this patient?

Although IV fluids resolved his AKI, prerenal in etiology given the calculated FENa at 0.5%, his lactate levels continued to uptrend to a peak of 4.0 mmol/L complicated by elevated blood pressure (BP) > 150/100 mm Hg. Given his thoracic aneurysm, his BP was treated with metoprolol tartrate and amlodipine 10 mg daily. The patient remained asymptomatic with no evidence of ischemia or sepsis.

We suspected the nebulizer treatments to be the etiology of the patient’s hyperlactatemia and subsequent anion-gap metabolic acidosis. His scheduled albuterol and ipratropium nebulizer treatments were discontinued, and the patient experienced rapid resolution of his anion gap and hyperlactatemia to 1.2 mmol/L over 24 hours. On discontinuation of the nebulization therapy, mild wheezing was noted on physical examination. The patient reported no symptoms and was at his baseline. The patient finished his antibiotic course for his community-acquired pneumonia and was discharged in stable condition with instructions to continue his previously established home COPD medication regimen of umeclidinium/vilanterol 62.5/25 mcg daily and albuterol metered-dose inhaler as needed.

Discussion

Short-acting β-agonists, such as albuterol, are widely used in COPD and are a guideline-recommended treatment in maintenance and exacerbation of asthma and COPD.¹ Short-acting β-agonist adverse effects (AEs) include nausea, vomiting, tremors, headache, and tachycardia; abnormal laboratory results include hypocalcemia, hypokalemia, hypophosphatemia, hypomagnesemia, and hyperglycemia.^2,3 Albuterol-induced hyperlactatemia and lactic acidosis also are known but often overlooked and underreported AEs.

In a randomized control trial, researchers identified a positive correlation between nebulized albuterol use and hyperlactatemia in asthmatics with asthma exacerbation.⁴ One systematic review identified ≤ 20% of patients on either IV or nebulized high-dose treatments with selective β2-agonists may experience hyperlactatemia.⁵ However, aerosolized administration of albuterol as opposed to IV administration is less likely to result in AEs and abnormal laboratory results given decreased systemic absorption.³

Hyperlactatemia and lactic acidosis are associated with increased morbidity and mortality.⁶ Lactic acidosis is classified as either type A or type B. Type A lactic acidosis is characterized by hypoperfusion as subsequent ischemic injuries lead to anaerobic metabolism and elevated lactate. Diseases such as septic, cardiogenic, and hypovolemic shock are often associated with type A lactic acidosis. Type B lactic acidosis, however, encapsulates all nonhypoperfusion-related elevations in lactate, including malignancy, ethanol intoxication, and medication-induced lactic acidosis.^7,8

In this case, the diagnosis was elusive as the patient had multiple comorbidities. His history included COPD, which is associated with elevated lactate levels.⁵ However, his initial laboratory workup did not show an anion gap, confirming a lack of an underlying acidotic process on admission. Because the patient was admitted for pneumonia, a known infectious source, complicated by an acute elevation in lactate, sepsis must be and was effectively ruled out. The patient also reported alcohol use during his admission, which confounded his presentation but was unlikely to impact the etiology of his lactic acidosis, given the unremarkable β-hydroxybutyrate and serum alcohol levels.

Conclusions

We encourage heightened clinical suspicion of albuterol-induced lactic acidosis in acutely ill patients with COPD on albuterol therapy on rule out of life-threatening etiologies and suggest transitioning patients from scheduled to as-needed albuterol treatments on symptomatic improvement in the clinical course. With such, we hope for improved patient outcomes and the prudent use of health care resources.

An 88-year-old male veteran with a medical history of chronic obstructive pulmonary disease (COPD) on home oxygen, chronic alcohol use, squamous cell carcinoma of the lung status after left upper lobectomy, and a 5.7 cm thoracic aortic aneurysm was admitted to the inpatient medical service for progressive dyspnea and productive cough. The patient was in his usual state of health until 2 days before presentation. A chest computed tomography scan showed a right lower lobe infiltrate, concerning for pneumonia, and stable thoracic aortic aneurysm (Figure). On admission, the patient was started on IV ceftriaxone 2 g daily for pneumonia and nebulizer therapy of combined albuterol 15 mg and ipratropium 1,500 mg every 6 hours for symptomatic treatment of his dyspnea.

The patient responded well to therapy, and his cough and dyspnea improved. However, 72 hours after admission, he developed an asymptomatic acute kidney injury (AKI) and anion-gap metabolic acidosis. His serum creatinine increased from baseline 0.6 mg/dL to 1.2 mg/dL. He also had an anion gap of 21 mmol/L and a decrease in bicarbonate from 23 mmol/L to 17 mmol/L. His condition was further complicated by new-onset hypertension (153/111 mm Hg). His calculated fractional excretion of sodium (FENa) was 0.5%, and his lactate level returned elevated at 3.6 mmol/L. On further investigation, he reported alcohol use the night prior; however, his β-hydroxybutyrate was negative, and serum alcohol level was undetectable. Meanwhile, the patient continued to receive antibiotics and scheduled nebulizer treatments. Although his AKI resolved with initial fluid resuscitation, his repeat lactate levels continued to trend upward to a peak of 4.0 mmol/L.

• What is your diagnosis?
• How would you treat this patient?

Although IV fluids resolved his AKI, prerenal in etiology given the calculated FENa at 0.5%, his lactate levels continued to uptrend to a peak of 4.0 mmol/L complicated by elevated blood pressure (BP) > 150/100 mm Hg. Given his thoracic aneurysm, his BP was treated with metoprolol tartrate and amlodipine 10 mg daily. The patient remained asymptomatic with no evidence of ischemia or sepsis.

We suspected the nebulizer treatments to be the etiology of the patient’s hyperlactatemia and subsequent anion-gap metabolic acidosis. His scheduled albuterol and ipratropium nebulizer treatments were discontinued, and the patient experienced rapid resolution of his anion gap and hyperlactatemia to 1.2 mmol/L over 24 hours. On discontinuation of the nebulization therapy, mild wheezing was noted on physical examination. The patient reported no symptoms and was at his baseline. The patient finished his antibiotic course for his community-acquired pneumonia and was discharged in stable condition with instructions to continue his previously established home COPD medication regimen of umeclidinium/vilanterol 62.5/25 mcg daily and albuterol metered-dose inhaler as needed.

Discussion

Short-acting β-agonists, such as albuterol, are widely used in COPD and are a guideline-recommended treatment in maintenance and exacerbation of asthma and COPD.¹ Short-acting β-agonist adverse effects (AEs) include nausea, vomiting, tremors, headache, and tachycardia; abnormal laboratory results include hypocalcemia, hypokalemia, hypophosphatemia, hypomagnesemia, and hyperglycemia.^2,3 Albuterol-induced hyperlactatemia and lactic acidosis also are known but often overlooked and underreported AEs.

In a randomized control trial, researchers identified a positive correlation between nebulized albuterol use and hyperlactatemia in asthmatics with asthma exacerbation.⁴ One systematic review identified ≤ 20% of patients on either IV or nebulized high-dose treatments with selective β2-agonists may experience hyperlactatemia.⁵ However, aerosolized administration of albuterol as opposed to IV administration is less likely to result in AEs and abnormal laboratory results given decreased systemic absorption.³

Hyperlactatemia and lactic acidosis are associated with increased morbidity and mortality.⁶ Lactic acidosis is classified as either type A or type B. Type A lactic acidosis is characterized by hypoperfusion as subsequent ischemic injuries lead to anaerobic metabolism and elevated lactate. Diseases such as septic, cardiogenic, and hypovolemic shock are often associated with type A lactic acidosis. Type B lactic acidosis, however, encapsulates all nonhypoperfusion-related elevations in lactate, including malignancy, ethanol intoxication, and medication-induced lactic acidosis.^7,8

In this case, the diagnosis was elusive as the patient had multiple comorbidities. His history included COPD, which is associated with elevated lactate levels.⁵ However, his initial laboratory workup did not show an anion gap, confirming a lack of an underlying acidotic process on admission. Because the patient was admitted for pneumonia, a known infectious source, complicated by an acute elevation in lactate, sepsis must be and was effectively ruled out. The patient also reported alcohol use during his admission, which confounded his presentation but was unlikely to impact the etiology of his lactic acidosis, given the unremarkable β-hydroxybutyrate and serum alcohol levels.

Conclusions

We encourage heightened clinical suspicion of albuterol-induced lactic acidosis in acutely ill patients with COPD on albuterol therapy on rule out of life-threatening etiologies and suggest transitioning patients from scheduled to as-needed albuterol treatments on symptomatic improvement in the clinical course. With such, we hope for improved patient outcomes and the prudent use of health care resources.

An 88-year-old male veteran with a medical history of chronic obstructive pulmonary disease (COPD) on home oxygen, chronic alcohol use, squamous cell carcinoma of the lung status after left upper lobectomy, and a 5.7 cm thoracic aortic aneurysm was admitted to the inpatient medical service for progressive dyspnea and productive cough. The patient was in his usual state of health until 2 days before presentation. A chest computed tomography scan showed a right lower lobe infiltrate, concerning for pneumonia, and stable thoracic aortic aneurysm (Figure). On admission, the patient was started on IV ceftriaxone 2 g daily for pneumonia and nebulizer therapy of combined albuterol 15 mg and ipratropium 1,500 mg every 6 hours for symptomatic treatment of his dyspnea.

The patient responded well to therapy, and his cough and dyspnea improved. However, 72 hours after admission, he developed an asymptomatic acute kidney injury (AKI) and anion-gap metabolic acidosis. His serum creatinine increased from baseline 0.6 mg/dL to 1.2 mg/dL. He also had an anion gap of 21 mmol/L and a decrease in bicarbonate from 23 mmol/L to 17 mmol/L. His condition was further complicated by new-onset hypertension (153/111 mm Hg). His calculated fractional excretion of sodium (FENa) was 0.5%, and his lactate level returned elevated at 3.6 mmol/L. On further investigation, he reported alcohol use the night prior; however, his β-hydroxybutyrate was negative, and serum alcohol level was undetectable. Meanwhile, the patient continued to receive antibiotics and scheduled nebulizer treatments. Although his AKI resolved with initial fluid resuscitation, his repeat lactate levels continued to trend upward to a peak of 4.0 mmol/L.

• What is your diagnosis?
• How would you treat this patient?

Although IV fluids resolved his AKI, prerenal in etiology given the calculated FENa at 0.5%, his lactate levels continued to uptrend to a peak of 4.0 mmol/L complicated by elevated blood pressure (BP) > 150/100 mm Hg. Given his thoracic aneurysm, his BP was treated with metoprolol tartrate and amlodipine 10 mg daily. The patient remained asymptomatic with no evidence of ischemia or sepsis.

We suspected the nebulizer treatments to be the etiology of the patient’s hyperlactatemia and subsequent anion-gap metabolic acidosis. His scheduled albuterol and ipratropium nebulizer treatments were discontinued, and the patient experienced rapid resolution of his anion gap and hyperlactatemia to 1.2 mmol/L over 24 hours. On discontinuation of the nebulization therapy, mild wheezing was noted on physical examination. The patient reported no symptoms and was at his baseline. The patient finished his antibiotic course for his community-acquired pneumonia and was discharged in stable condition with instructions to continue his previously established home COPD medication regimen of umeclidinium/vilanterol 62.5/25 mcg daily and albuterol metered-dose inhaler as needed.

Discussion

Short-acting β-agonists, such as albuterol, are widely used in COPD and are a guideline-recommended treatment in maintenance and exacerbation of asthma and COPD.¹ Short-acting β-agonist adverse effects (AEs) include nausea, vomiting, tremors, headache, and tachycardia; abnormal laboratory results include hypocalcemia, hypokalemia, hypophosphatemia, hypomagnesemia, and hyperglycemia.^2,3 Albuterol-induced hyperlactatemia and lactic acidosis also are known but often overlooked and underreported AEs.

In a randomized control trial, researchers identified a positive correlation between nebulized albuterol use and hyperlactatemia in asthmatics with asthma exacerbation.⁴ One systematic review identified ≤ 20% of patients on either IV or nebulized high-dose treatments with selective β2-agonists may experience hyperlactatemia.⁵ However, aerosolized administration of albuterol as opposed to IV administration is less likely to result in AEs and abnormal laboratory results given decreased systemic absorption.³

Hyperlactatemia and lactic acidosis are associated with increased morbidity and mortality.⁶ Lactic acidosis is classified as either type A or type B. Type A lactic acidosis is characterized by hypoperfusion as subsequent ischemic injuries lead to anaerobic metabolism and elevated lactate. Diseases such as septic, cardiogenic, and hypovolemic shock are often associated with type A lactic acidosis. Type B lactic acidosis, however, encapsulates all nonhypoperfusion-related elevations in lactate, including malignancy, ethanol intoxication, and medication-induced lactic acidosis.^7,8

In this case, the diagnosis was elusive as the patient had multiple comorbidities. His history included COPD, which is associated with elevated lactate levels.⁵ However, his initial laboratory workup did not show an anion gap, confirming a lack of an underlying acidotic process on admission. Because the patient was admitted for pneumonia, a known infectious source, complicated by an acute elevation in lactate, sepsis must be and was effectively ruled out. The patient also reported alcohol use during his admission, which confounded his presentation but was unlikely to impact the etiology of his lactic acidosis, given the unremarkable β-hydroxybutyrate and serum alcohol levels.

Conclusions

We encourage heightened clinical suspicion of albuterol-induced lactic acidosis in acutely ill patients with COPD on albuterol therapy on rule out of life-threatening etiologies and suggest transitioning patients from scheduled to as-needed albuterol treatments on symptomatic improvement in the clinical course. With such, we hope for improved patient outcomes and the prudent use of health care resources.

Delirium is a condition commonly exhibited by hospitalized patients and by those who are approaching the end of life.¹ Patients who experience a disturbance in attention that develops over a relatively short period and represents an acute change may have delirium.² Furthermore, there is often an additional cognitive disturbance, such as disorientation, memory deficit, language deficits, visuospatial deficit, or perception. Terminal delirium is defined as delirium that occurs in the dying process and implies that reversal is less likely.³ When death is anticipated, diagnostic workups are not recommended, and treatment of the physiologic abnormalities that contribute to delirium is generally ineffective.⁴

Background

Delirium is often underdiagnosed and undetected by the clinician. Some studies have shown that delirium is not detected in 22 to 50% of cases.⁵ Factors that contribute to the underdetection of delirium include preexisting dementia, older age, presence of visual or hearing impairment, and hypoactive presentation of delirium. Other possible reasons for nondetection of delirium are its fluctuating nature and lack of formal cognitive assessment as part of a routine screening across care settings.⁵ Another study found that 41% of health care providers (HCPs) felt that screening for delirium was burdensome.⁶

To date, there are no veteran-focused studies that investigate prevalence or risk factors for terminal delirium in US Department of Veterans Affairs (VA) long-term care hospice units. Most long-term care hospice units in the VA are in community living centers (CLCs) that follow regulatory guidelines for using antipsychotic medications. The Centers for Medicare and Medicaid Services state that if antipsychotics are prescribed, documentation must clearly show the indication for the antipsychotic medication, the multiple attempts to implement planned care, nonpharmacologic approaches, and ongoing evaluation of the effectiveness of these interventions.⁷ The symptoms of terminal delirium cause significant distress to patients, family and caregivers, and nursing staff. Literature suggests that delirium poses significant relational challenges for patients, families, and HCPs in end-of-life situations.^8,9 We hypothesize that the early identification of risk factors for the development of terminal delirium in this population may lead to increased use of nonpharmacologic measures to prevent terminal delirium, increase nursing vigilance for development of symptoms, and reduce symptom burden should terminal delirium develop.

Prevalence of delirium in the long-term care setting has ranged between 1.4 and 70.3%.¹⁰ The rate was found to be much higher in institutionalized populations compared with that of patients classified as at-home. In a study of the prevalence, severity, and natural history of neuropsychiatric syndromes in terminally ill veterans enrolled in community hospice, delirium was found to be present in only 4.1% on the initial visit and 42.5% during last visit. Also, more than half had at least 1 episode of delirium during the 90-day study period.¹¹ In a study of the prevalence of delirium in terminal cancer patients admitted to hospice, 80% experienced delirium in their final days.¹²

Risk factors for the development of delirium that have been identified in actively dying patients include bowel or bladder obstruction, fluid and electrolyte imbalances, suboptimal pain management, medication adverse effects and toxicity (eg, benzodiazepines, opioids, anticholinergics, and steroids), the addition of ≥ 3 medications, infection, hepatic and renal failure, poor glycemic control, hypoxia, and hematologic disturbances.^4,5,13 A high percentage of patients with a previous diagnosis of dementia were found to exhibit terminal delirium.¹⁴

There are 2 major subtypes of delirium: hyperactive and hypoactive.⁴ Patients with hypoactive delirium exhibit lethargy, reduced motor activity, lack of interest, and/or incoherent speech. There is currently little evidence to guide the treatment of hypoactive delirium. By contrast, hyperactive delirium is associated with hallucinations, agitation, heightened arousal, and inappropriate behavior. Many studies suggest both nonpharmacologic and pharmacologic treatment modalities for the treatment of hyperactive delirium.^4,13 Nonpharmacologic interventions may minimize the risk and severity of symptoms associated with delirium. Current guidelines recommend these interventions before pharmacologic treatment.⁴ Nonpharmacologic interventions include but are not limited to the following: engaging the patient in mentally stimulating activities; surrounding the patient with familiar materials (eg, photos); ensuring that all individuals identify themselves when they encounter a patient; minimizing the intensity of stimulation, providing family or volunteer presence, soft lighting and warm blankets; and ensuring the patient uses hearing aids and glasses if needed.^4,14

Although there are no US Food and Drug Administration-approved medications to treat hyperactive delirium, first-generation antipsychotics (eg, haloperidol, chlorpromazine) are considered the first-line treatment for patients exhibiting psychosis and psychomotor agitation.^3,4,14-16 In terminally ill patients, there is limited evidence from clinical trials to support the efficacy of drug therapy.¹⁴ One study showed lack of efficacy with hydration and opioid rotation.¹⁷ In terminally ill patients experiencing hyperactive delirium, there is a significant increased risk of muscle tension, myoclonic seizures, and distress to the patient, family, and caregiver.¹ Benzodiazepines can be considered first-line treatment for dying patients with terminal delirium in which the goals of treatment are to relieve muscle tension, ensure amnesia, reduce the risk of seizures, and decrease psychosis and agitation.^18,19 Furthermore, in patients with history of alcohol misuse who are experiencing terminal delirium, benzodiazepines also may be the preferred pharmacologic treatment.²⁰ Caution must be exercised with the use of benzodiazepines because they can also cause oversedation, increased confusion, and/or a paradoxical worsening of delirium.^3,4,14

Methods

This was a retrospective case-control study of patients who died in the Edward Hines Jr. Veterans Affairs Hospital CLC in Hines, Illinois, under the treating specialty nursing home hospice from October 1, 2013 to September 30, 2015. Due to the retrospective nature of this trial, the use of antipsychotics within the last 2 weeks of life was a surrogate marker for development of terminal delirium. Cases were defined as patients who were treated with antipsychotics for terminal delirium within the last 2 weeks of their lives. Controls were defined as patients who were not treated with antipsychotics for terminal delirium within the last 2 weeks of their lives. Living hospice patients and patients who were discharged from the CLC before death were excluded.

The goals of this study were to (1) determine risk factors in the VA CLC hospice veteran population for the development of terminal delirium; (2) evaluate documentation by the nursing staff of nonpharmacologic interventions and indications for antipsychotic use in the treatment of terminal delirium; and (3) examine the current usage patterns of antipsychotics for the treatment of terminal delirium.

Veterans’ medical records were reviewed from 2 weeks before death until the recorded death date. Factors that were assessed included age, war era of service, date of death, terminal diagnosis, time interval from cancer diagnosis to death, comorbid conditions, prescribed antipsychotic medications, and other medications potentially contributing to delirium. Nursing documentation was reviewed for indications for administration of antipsychotic medications and nonpharmacologic interventions used to mitigate the symptoms of terminal delirium.

Statistical analysis was conducted in SAS Version 9.3. Cases were compared with controls using univariate and multivariate statistics as appropriate. Comparisons for continuous variables (eg, age) were conducted with Student t tests. Categorical variables (eg, PTSD diagnosis) were compared using χ² analysis or Fisher exact test as appropriate. Variables with a P value < .1 in the univariate analysis were included in logistic regression models. Independent variables were removed from the models, using a backward selection process. Interaction terms were tested based on significance and clinical relevance. A P value < .05 was considered statistically significant.

Results

From October 1, 2013 to September 30, 2015, 307 patients were analyzed for inclusion in this study. Within this population, 186 received antipsychotic medications for the treatment of terminal delirium (cases), while 90 did not receive antipsychotics (controls). Of the 31 excluded patients, 13 were discharged to receive home hospice care, 11 were discharged to community nursing homes, 5 died in acute care units of Edward Hines, Jr. VA Hospital, and 2 died outside of the study period.

The mean age of all included patients was 75.5 years, and the most common terminal diagnosis was cancer, which occurred in 156 patients (56.5%) (Table 1). The baseline characteristics were similar between the cases and controls, including war era of veteran, terminal diagnosis, and comorbid conditions. The mean time between cancer diagnosis and death was not notably longer in the control group compared with that of the case group (25 vs 16 mo, respectively). There was no statistically significant difference in terminal diagnoses between cases and controls. Veterans in the control group spent more days (mean [SD]) in the hospice unit compared with veterans who experienced terminal delirium (48.5 [168.4] vs 28.2 [46.9]; P = .01). Patients with suspected infections were more likely found in the control group (P = .04; odds ratio [OR] = 1.70; 95% CI, 1.02-2.82).

Several risk factors for terminal delirium were identified in this veteran population. Veterans with a history of drug or alcohol abuse were found to be at a significantly higher risk for terminal delirium (P = .04; OR, 1.87; 95% CI, 1.03-3.37). As noted in previous studies, steroid use (P = .01; OR, 2.57; 95% CI, 1.26-5.22); opioids (P = .007; OR, 5.94; 95% CI, 1.54-22.99), and anticholinergic medications (P = .01; OR, 2.06; 95% CI, 1.21-3.52) also increased the risk of delirium (Table 2).

Discussion

Terminal delirium is experienced by many individuals in their last days to weeks of life. Symptoms can present as hyperactive (eg, agitation, hallucinations, heightened arousal) or hypoactive (lethargy, reduced motor activity, incoherent speech). Hyperactive terminal delirium is particularly problematic because it causes increased distress to the patient, family, and caregivers. Delirium can lead to safety concerns, such as fall risk, due to patients’ decreased insight into functional decline.

Many studies suggest both nonpharmacologic and pharmacologic treatments for nonterminal delirium that may also apply to terminal delirium. Nonpharmacologic methods, such as providing a quiet and familiar environment, relieving urinary retention or constipation, and attending to sensory deficits may help prevent or minimize delirium. Pharmacologic interventions, such as antipsychotics or benzodiazepines, may benefit when other modalities have failed to assuage distressing symptoms of delirium. Because hypoactive delirium is usually accompanied by somnolence and reduced motor activity, medication is most often administered to individuals with hyperactive delirium.

The VA provides long-term care hospice beds in their CLCs for veterans who are nearing end of life and have inadequate caregiver support for comprehensive end-of-life care in the home (Case Presentation). Because of their military service and other factors common in their life histories, they may have a unique set of characteristics that are predictive of developing terminal delirium. Awareness of the propensity for terminal delirium will allow for early identification of symptoms, timely initiation of nonpharmacologic interventions, and potentially a decreased need for use of antipsychotic medications.

Limitations

Limitations to the current study include hyperactive delirium that was misinterpreted and treated as pain; the probable underreporting of hypoactive delirium and associated symptoms; the use of antipsychotics as a surrogate marker for the development of terminal delirium; and lack of nursing documentation of assessment and interventions of terminal delirium. In addition, the total milligrams of antipsychotics administered per patient were not collected. Finally, there was the potential that other risk factors were not identified due to low numbers of veterans with certain diagnoses (eg, dementia).

Conclusions

Based on the findings in this study, several steps have been implemented to enhance the care of veterans under hospice care in this CLC: (1) Nurses providing direct patient care have been educated on the assessment by use of the mRASS and treatment of terminal delirium;²² (2) A hospice delirium note template has been created that details symptoms of terminal delirium, nonpharmacologic interventions, the use of antipsychotic medications if indicated, and the outcome of interventions; (3) Providers (eg, physician, advanced practice nurses) review each veteran’s medical history for the risk factors noted above; (4) Any risk factor(s) identified by this study will lead to a nursing order for delirium precautions, which requires completion of the delirium note template by nurses each shift.

The goal for this enhanced process is to identify veterans at risk for terminal delirium, observe changes that may indicate the onset of delirium, and intervene promptly to decrease symptom burden and improve quality of life and safety. Potentially, there will be less requirement for the use of antipsychotic medications to control the more severe symptoms of terminal delirium. A future study will evaluate the outcome of this enhanced process for the assessment and treatment of terminal delirium in this veteran population.

Acknowledgment

We thank Martin J. Gorbien, MD, associate chief of staff of Geriatrics and Extended Care, for his continued support throughout this project.

Delirium is a condition commonly exhibited by hospitalized patients and by those who are approaching the end of life.¹ Patients who experience a disturbance in attention that develops over a relatively short period and represents an acute change may have delirium.² Furthermore, there is often an additional cognitive disturbance, such as disorientation, memory deficit, language deficits, visuospatial deficit, or perception. Terminal delirium is defined as delirium that occurs in the dying process and implies that reversal is less likely.³ When death is anticipated, diagnostic workups are not recommended, and treatment of the physiologic abnormalities that contribute to delirium is generally ineffective.⁴

Background

Delirium is often underdiagnosed and undetected by the clinician. Some studies have shown that delirium is not detected in 22 to 50% of cases.⁵ Factors that contribute to the underdetection of delirium include preexisting dementia, older age, presence of visual or hearing impairment, and hypoactive presentation of delirium. Other possible reasons for nondetection of delirium are its fluctuating nature and lack of formal cognitive assessment as part of a routine screening across care settings.⁵ Another study found that 41% of health care providers (HCPs) felt that screening for delirium was burdensome.⁶

To date, there are no veteran-focused studies that investigate prevalence or risk factors for terminal delirium in US Department of Veterans Affairs (VA) long-term care hospice units. Most long-term care hospice units in the VA are in community living centers (CLCs) that follow regulatory guidelines for using antipsychotic medications. The Centers for Medicare and Medicaid Services state that if antipsychotics are prescribed, documentation must clearly show the indication for the antipsychotic medication, the multiple attempts to implement planned care, nonpharmacologic approaches, and ongoing evaluation of the effectiveness of these interventions.⁷ The symptoms of terminal delirium cause significant distress to patients, family and caregivers, and nursing staff. Literature suggests that delirium poses significant relational challenges for patients, families, and HCPs in end-of-life situations.^8,9 We hypothesize that the early identification of risk factors for the development of terminal delirium in this population may lead to increased use of nonpharmacologic measures to prevent terminal delirium, increase nursing vigilance for development of symptoms, and reduce symptom burden should terminal delirium develop.

Prevalence of delirium in the long-term care setting has ranged between 1.4 and 70.3%.¹⁰ The rate was found to be much higher in institutionalized populations compared with that of patients classified as at-home. In a study of the prevalence, severity, and natural history of neuropsychiatric syndromes in terminally ill veterans enrolled in community hospice, delirium was found to be present in only 4.1% on the initial visit and 42.5% during last visit. Also, more than half had at least 1 episode of delirium during the 90-day study period.¹¹ In a study of the prevalence of delirium in terminal cancer patients admitted to hospice, 80% experienced delirium in their final days.¹²

Risk factors for the development of delirium that have been identified in actively dying patients include bowel or bladder obstruction, fluid and electrolyte imbalances, suboptimal pain management, medication adverse effects and toxicity (eg, benzodiazepines, opioids, anticholinergics, and steroids), the addition of ≥ 3 medications, infection, hepatic and renal failure, poor glycemic control, hypoxia, and hematologic disturbances.^4,5,13 A high percentage of patients with a previous diagnosis of dementia were found to exhibit terminal delirium.¹⁴

There are 2 major subtypes of delirium: hyperactive and hypoactive.⁴ Patients with hypoactive delirium exhibit lethargy, reduced motor activity, lack of interest, and/or incoherent speech. There is currently little evidence to guide the treatment of hypoactive delirium. By contrast, hyperactive delirium is associated with hallucinations, agitation, heightened arousal, and inappropriate behavior. Many studies suggest both nonpharmacologic and pharmacologic treatment modalities for the treatment of hyperactive delirium.^4,13 Nonpharmacologic interventions may minimize the risk and severity of symptoms associated with delirium. Current guidelines recommend these interventions before pharmacologic treatment.⁴ Nonpharmacologic interventions include but are not limited to the following: engaging the patient in mentally stimulating activities; surrounding the patient with familiar materials (eg, photos); ensuring that all individuals identify themselves when they encounter a patient; minimizing the intensity of stimulation, providing family or volunteer presence, soft lighting and warm blankets; and ensuring the patient uses hearing aids and glasses if needed.^4,14

Although there are no US Food and Drug Administration-approved medications to treat hyperactive delirium, first-generation antipsychotics (eg, haloperidol, chlorpromazine) are considered the first-line treatment for patients exhibiting psychosis and psychomotor agitation.^3,4,14-16 In terminally ill patients, there is limited evidence from clinical trials to support the efficacy of drug therapy.¹⁴ One study showed lack of efficacy with hydration and opioid rotation.¹⁷ In terminally ill patients experiencing hyperactive delirium, there is a significant increased risk of muscle tension, myoclonic seizures, and distress to the patient, family, and caregiver.¹ Benzodiazepines can be considered first-line treatment for dying patients with terminal delirium in which the goals of treatment are to relieve muscle tension, ensure amnesia, reduce the risk of seizures, and decrease psychosis and agitation.^18,19 Furthermore, in patients with history of alcohol misuse who are experiencing terminal delirium, benzodiazepines also may be the preferred pharmacologic treatment.²⁰ Caution must be exercised with the use of benzodiazepines because they can also cause oversedation, increased confusion, and/or a paradoxical worsening of delirium.^3,4,14

Methods

This was a retrospective case-control study of patients who died in the Edward Hines Jr. Veterans Affairs Hospital CLC in Hines, Illinois, under the treating specialty nursing home hospice from October 1, 2013 to September 30, 2015. Due to the retrospective nature of this trial, the use of antipsychotics within the last 2 weeks of life was a surrogate marker for development of terminal delirium. Cases were defined as patients who were treated with antipsychotics for terminal delirium within the last 2 weeks of their lives. Controls were defined as patients who were not treated with antipsychotics for terminal delirium within the last 2 weeks of their lives. Living hospice patients and patients who were discharged from the CLC before death were excluded.

The goals of this study were to (1) determine risk factors in the VA CLC hospice veteran population for the development of terminal delirium; (2) evaluate documentation by the nursing staff of nonpharmacologic interventions and indications for antipsychotic use in the treatment of terminal delirium; and (3) examine the current usage patterns of antipsychotics for the treatment of terminal delirium.

Veterans’ medical records were reviewed from 2 weeks before death until the recorded death date. Factors that were assessed included age, war era of service, date of death, terminal diagnosis, time interval from cancer diagnosis to death, comorbid conditions, prescribed antipsychotic medications, and other medications potentially contributing to delirium. Nursing documentation was reviewed for indications for administration of antipsychotic medications and nonpharmacologic interventions used to mitigate the symptoms of terminal delirium.

Statistical analysis was conducted in SAS Version 9.3. Cases were compared with controls using univariate and multivariate statistics as appropriate. Comparisons for continuous variables (eg, age) were conducted with Student t tests. Categorical variables (eg, PTSD diagnosis) were compared using χ² analysis or Fisher exact test as appropriate. Variables with a P value < .1 in the univariate analysis were included in logistic regression models. Independent variables were removed from the models, using a backward selection process. Interaction terms were tested based on significance and clinical relevance. A P value < .05 was considered statistically significant.

Results

From October 1, 2013 to September 30, 2015, 307 patients were analyzed for inclusion in this study. Within this population, 186 received antipsychotic medications for the treatment of terminal delirium (cases), while 90 did not receive antipsychotics (controls). Of the 31 excluded patients, 13 were discharged to receive home hospice care, 11 were discharged to community nursing homes, 5 died in acute care units of Edward Hines, Jr. VA Hospital, and 2 died outside of the study period.

The mean age of all included patients was 75.5 years, and the most common terminal diagnosis was cancer, which occurred in 156 patients (56.5%) (Table 1). The baseline characteristics were similar between the cases and controls, including war era of veteran, terminal diagnosis, and comorbid conditions. The mean time between cancer diagnosis and death was not notably longer in the control group compared with that of the case group (25 vs 16 mo, respectively). There was no statistically significant difference in terminal diagnoses between cases and controls. Veterans in the control group spent more days (mean [SD]) in the hospice unit compared with veterans who experienced terminal delirium (48.5 [168.4] vs 28.2 [46.9]; P = .01). Patients with suspected infections were more likely found in the control group (P = .04; odds ratio [OR] = 1.70; 95% CI, 1.02-2.82).

Several risk factors for terminal delirium were identified in this veteran population. Veterans with a history of drug or alcohol abuse were found to be at a significantly higher risk for terminal delirium (P = .04; OR, 1.87; 95% CI, 1.03-3.37). As noted in previous studies, steroid use (P = .01; OR, 2.57; 95% CI, 1.26-5.22); opioids (P = .007; OR, 5.94; 95% CI, 1.54-22.99), and anticholinergic medications (P = .01; OR, 2.06; 95% CI, 1.21-3.52) also increased the risk of delirium (Table 2).

Discussion

Terminal delirium is experienced by many individuals in their last days to weeks of life. Symptoms can present as hyperactive (eg, agitation, hallucinations, heightened arousal) or hypoactive (lethargy, reduced motor activity, incoherent speech). Hyperactive terminal delirium is particularly problematic because it causes increased distress to the patient, family, and caregivers. Delirium can lead to safety concerns, such as fall risk, due to patients’ decreased insight into functional decline.

Many studies suggest both nonpharmacologic and pharmacologic treatments for nonterminal delirium that may also apply to terminal delirium. Nonpharmacologic methods, such as providing a quiet and familiar environment, relieving urinary retention or constipation, and attending to sensory deficits may help prevent or minimize delirium. Pharmacologic interventions, such as antipsychotics or benzodiazepines, may benefit when other modalities have failed to assuage distressing symptoms of delirium. Because hypoactive delirium is usually accompanied by somnolence and reduced motor activity, medication is most often administered to individuals with hyperactive delirium.

The VA provides long-term care hospice beds in their CLCs for veterans who are nearing end of life and have inadequate caregiver support for comprehensive end-of-life care in the home (Case Presentation). Because of their military service and other factors common in their life histories, they may have a unique set of characteristics that are predictive of developing terminal delirium. Awareness of the propensity for terminal delirium will allow for early identification of symptoms, timely initiation of nonpharmacologic interventions, and potentially a decreased need for use of antipsychotic medications.

Limitations

Limitations to the current study include hyperactive delirium that was misinterpreted and treated as pain; the probable underreporting of hypoactive delirium and associated symptoms; the use of antipsychotics as a surrogate marker for the development of terminal delirium; and lack of nursing documentation of assessment and interventions of terminal delirium. In addition, the total milligrams of antipsychotics administered per patient were not collected. Finally, there was the potential that other risk factors were not identified due to low numbers of veterans with certain diagnoses (eg, dementia).

Conclusions

Based on the findings in this study, several steps have been implemented to enhance the care of veterans under hospice care in this CLC: (1) Nurses providing direct patient care have been educated on the assessment by use of the mRASS and treatment of terminal delirium;²² (2) A hospice delirium note template has been created that details symptoms of terminal delirium, nonpharmacologic interventions, the use of antipsychotic medications if indicated, and the outcome of interventions; (3) Providers (eg, physician, advanced practice nurses) review each veteran’s medical history for the risk factors noted above; (4) Any risk factor(s) identified by this study will lead to a nursing order for delirium precautions, which requires completion of the delirium note template by nurses each shift.

The goal for this enhanced process is to identify veterans at risk for terminal delirium, observe changes that may indicate the onset of delirium, and intervene promptly to decrease symptom burden and improve quality of life and safety. Potentially, there will be less requirement for the use of antipsychotic medications to control the more severe symptoms of terminal delirium. A future study will evaluate the outcome of this enhanced process for the assessment and treatment of terminal delirium in this veteran population.

Acknowledgment

We thank Martin J. Gorbien, MD, associate chief of staff of Geriatrics and Extended Care, for his continued support throughout this project.

Delirium is a condition commonly exhibited by hospitalized patients and by those who are approaching the end of life.¹ Patients who experience a disturbance in attention that develops over a relatively short period and represents an acute change may have delirium.² Furthermore, there is often an additional cognitive disturbance, such as disorientation, memory deficit, language deficits, visuospatial deficit, or perception. Terminal delirium is defined as delirium that occurs in the dying process and implies that reversal is less likely.³ When death is anticipated, diagnostic workups are not recommended, and treatment of the physiologic abnormalities that contribute to delirium is generally ineffective.⁴

Background

Delirium is often underdiagnosed and undetected by the clinician. Some studies have shown that delirium is not detected in 22 to 50% of cases.⁵ Factors that contribute to the underdetection of delirium include preexisting dementia, older age, presence of visual or hearing impairment, and hypoactive presentation of delirium. Other possible reasons for nondetection of delirium are its fluctuating nature and lack of formal cognitive assessment as part of a routine screening across care settings.⁵ Another study found that 41% of health care providers (HCPs) felt that screening for delirium was burdensome.⁶

To date, there are no veteran-focused studies that investigate prevalence or risk factors for terminal delirium in US Department of Veterans Affairs (VA) long-term care hospice units. Most long-term care hospice units in the VA are in community living centers (CLCs) that follow regulatory guidelines for using antipsychotic medications. The Centers for Medicare and Medicaid Services state that if antipsychotics are prescribed, documentation must clearly show the indication for the antipsychotic medication, the multiple attempts to implement planned care, nonpharmacologic approaches, and ongoing evaluation of the effectiveness of these interventions.⁷ The symptoms of terminal delirium cause significant distress to patients, family and caregivers, and nursing staff. Literature suggests that delirium poses significant relational challenges for patients, families, and HCPs in end-of-life situations.^8,9 We hypothesize that the early identification of risk factors for the development of terminal delirium in this population may lead to increased use of nonpharmacologic measures to prevent terminal delirium, increase nursing vigilance for development of symptoms, and reduce symptom burden should terminal delirium develop.

Prevalence of delirium in the long-term care setting has ranged between 1.4 and 70.3%.¹⁰ The rate was found to be much higher in institutionalized populations compared with that of patients classified as at-home. In a study of the prevalence, severity, and natural history of neuropsychiatric syndromes in terminally ill veterans enrolled in community hospice, delirium was found to be present in only 4.1% on the initial visit and 42.5% during last visit. Also, more than half had at least 1 episode of delirium during the 90-day study period.¹¹ In a study of the prevalence of delirium in terminal cancer patients admitted to hospice, 80% experienced delirium in their final days.¹²

Risk factors for the development of delirium that have been identified in actively dying patients include bowel or bladder obstruction, fluid and electrolyte imbalances, suboptimal pain management, medication adverse effects and toxicity (eg, benzodiazepines, opioids, anticholinergics, and steroids), the addition of ≥ 3 medications, infection, hepatic and renal failure, poor glycemic control, hypoxia, and hematologic disturbances.^4,5,13 A high percentage of patients with a previous diagnosis of dementia were found to exhibit terminal delirium.¹⁴

There are 2 major subtypes of delirium: hyperactive and hypoactive.⁴ Patients with hypoactive delirium exhibit lethargy, reduced motor activity, lack of interest, and/or incoherent speech. There is currently little evidence to guide the treatment of hypoactive delirium. By contrast, hyperactive delirium is associated with hallucinations, agitation, heightened arousal, and inappropriate behavior. Many studies suggest both nonpharmacologic and pharmacologic treatment modalities for the treatment of hyperactive delirium.^4,13 Nonpharmacologic interventions may minimize the risk and severity of symptoms associated with delirium. Current guidelines recommend these interventions before pharmacologic treatment.⁴ Nonpharmacologic interventions include but are not limited to the following: engaging the patient in mentally stimulating activities; surrounding the patient with familiar materials (eg, photos); ensuring that all individuals identify themselves when they encounter a patient; minimizing the intensity of stimulation, providing family or volunteer presence, soft lighting and warm blankets; and ensuring the patient uses hearing aids and glasses if needed.^4,14

Although there are no US Food and Drug Administration-approved medications to treat hyperactive delirium, first-generation antipsychotics (eg, haloperidol, chlorpromazine) are considered the first-line treatment for patients exhibiting psychosis and psychomotor agitation.^3,4,14-16 In terminally ill patients, there is limited evidence from clinical trials to support the efficacy of drug therapy.¹⁴ One study showed lack of efficacy with hydration and opioid rotation.¹⁷ In terminally ill patients experiencing hyperactive delirium, there is a significant increased risk of muscle tension, myoclonic seizures, and distress to the patient, family, and caregiver.¹ Benzodiazepines can be considered first-line treatment for dying patients with terminal delirium in which the goals of treatment are to relieve muscle tension, ensure amnesia, reduce the risk of seizures, and decrease psychosis and agitation.^18,19 Furthermore, in patients with history of alcohol misuse who are experiencing terminal delirium, benzodiazepines also may be the preferred pharmacologic treatment.²⁰ Caution must be exercised with the use of benzodiazepines because they can also cause oversedation, increased confusion, and/or a paradoxical worsening of delirium.^3,4,14

Methods

This was a retrospective case-control study of patients who died in the Edward Hines Jr. Veterans Affairs Hospital CLC in Hines, Illinois, under the treating specialty nursing home hospice from October 1, 2013 to September 30, 2015. Due to the retrospective nature of this trial, the use of antipsychotics within the last 2 weeks of life was a surrogate marker for development of terminal delirium. Cases were defined as patients who were treated with antipsychotics for terminal delirium within the last 2 weeks of their lives. Controls were defined as patients who were not treated with antipsychotics for terminal delirium within the last 2 weeks of their lives. Living hospice patients and patients who were discharged from the CLC before death were excluded.

The goals of this study were to (1) determine risk factors in the VA CLC hospice veteran population for the development of terminal delirium; (2) evaluate documentation by the nursing staff of nonpharmacologic interventions and indications for antipsychotic use in the treatment of terminal delirium; and (3) examine the current usage patterns of antipsychotics for the treatment of terminal delirium.

Veterans’ medical records were reviewed from 2 weeks before death until the recorded death date. Factors that were assessed included age, war era of service, date of death, terminal diagnosis, time interval from cancer diagnosis to death, comorbid conditions, prescribed antipsychotic medications, and other medications potentially contributing to delirium. Nursing documentation was reviewed for indications for administration of antipsychotic medications and nonpharmacologic interventions used to mitigate the symptoms of terminal delirium.

Statistical analysis was conducted in SAS Version 9.3. Cases were compared with controls using univariate and multivariate statistics as appropriate. Comparisons for continuous variables (eg, age) were conducted with Student t tests. Categorical variables (eg, PTSD diagnosis) were compared using χ² analysis or Fisher exact test as appropriate. Variables with a P value < .1 in the univariate analysis were included in logistic regression models. Independent variables were removed from the models, using a backward selection process. Interaction terms were tested based on significance and clinical relevance. A P value < .05 was considered statistically significant.

Results

From October 1, 2013 to September 30, 2015, 307 patients were analyzed for inclusion in this study. Within this population, 186 received antipsychotic medications for the treatment of terminal delirium (cases), while 90 did not receive antipsychotics (controls). Of the 31 excluded patients, 13 were discharged to receive home hospice care, 11 were discharged to community nursing homes, 5 died in acute care units of Edward Hines, Jr. VA Hospital, and 2 died outside of the study period.

The mean age of all included patients was 75.5 years, and the most common terminal diagnosis was cancer, which occurred in 156 patients (56.5%) (Table 1). The baseline characteristics were similar between the cases and controls, including war era of veteran, terminal diagnosis, and comorbid conditions. The mean time between cancer diagnosis and death was not notably longer in the control group compared with that of the case group (25 vs 16 mo, respectively). There was no statistically significant difference in terminal diagnoses between cases and controls. Veterans in the control group spent more days (mean [SD]) in the hospice unit compared with veterans who experienced terminal delirium (48.5 [168.4] vs 28.2 [46.9]; P = .01). Patients with suspected infections were more likely found in the control group (P = .04; odds ratio [OR] = 1.70; 95% CI, 1.02-2.82).

Several risk factors for terminal delirium were identified in this veteran population. Veterans with a history of drug or alcohol abuse were found to be at a significantly higher risk for terminal delirium (P = .04; OR, 1.87; 95% CI, 1.03-3.37). As noted in previous studies, steroid use (P = .01; OR, 2.57; 95% CI, 1.26-5.22); opioids (P = .007; OR, 5.94; 95% CI, 1.54-22.99), and anticholinergic medications (P = .01; OR, 2.06; 95% CI, 1.21-3.52) also increased the risk of delirium (Table 2).

Discussion

Terminal delirium is experienced by many individuals in their last days to weeks of life. Symptoms can present as hyperactive (eg, agitation, hallucinations, heightened arousal) or hypoactive (lethargy, reduced motor activity, incoherent speech). Hyperactive terminal delirium is particularly problematic because it causes increased distress to the patient, family, and caregivers. Delirium can lead to safety concerns, such as fall risk, due to patients’ decreased insight into functional decline.

Many studies suggest both nonpharmacologic and pharmacologic treatments for nonterminal delirium that may also apply to terminal delirium. Nonpharmacologic methods, such as providing a quiet and familiar environment, relieving urinary retention or constipation, and attending to sensory deficits may help prevent or minimize delirium. Pharmacologic interventions, such as antipsychotics or benzodiazepines, may benefit when other modalities have failed to assuage distressing symptoms of delirium. Because hypoactive delirium is usually accompanied by somnolence and reduced motor activity, medication is most often administered to individuals with hyperactive delirium.

The VA provides long-term care hospice beds in their CLCs for veterans who are nearing end of life and have inadequate caregiver support for comprehensive end-of-life care in the home (Case Presentation). Because of their military service and other factors common in their life histories, they may have a unique set of characteristics that are predictive of developing terminal delirium. Awareness of the propensity for terminal delirium will allow for early identification of symptoms, timely initiation of nonpharmacologic interventions, and potentially a decreased need for use of antipsychotic medications.

Limitations

Limitations to the current study include hyperactive delirium that was misinterpreted and treated as pain; the probable underreporting of hypoactive delirium and associated symptoms; the use of antipsychotics as a surrogate marker for the development of terminal delirium; and lack of nursing documentation of assessment and interventions of terminal delirium. In addition, the total milligrams of antipsychotics administered per patient were not collected. Finally, there was the potential that other risk factors were not identified due to low numbers of veterans with certain diagnoses (eg, dementia).

Conclusions

Based on the findings in this study, several steps have been implemented to enhance the care of veterans under hospice care in this CLC: (1) Nurses providing direct patient care have been educated on the assessment by use of the mRASS and treatment of terminal delirium;²² (2) A hospice delirium note template has been created that details symptoms of terminal delirium, nonpharmacologic interventions, the use of antipsychotic medications if indicated, and the outcome of interventions; (3) Providers (eg, physician, advanced practice nurses) review each veteran’s medical history for the risk factors noted above; (4) Any risk factor(s) identified by this study will lead to a nursing order for delirium precautions, which requires completion of the delirium note template by nurses each shift.

The goal for this enhanced process is to identify veterans at risk for terminal delirium, observe changes that may indicate the onset of delirium, and intervene promptly to decrease symptom burden and improve quality of life and safety. Potentially, there will be less requirement for the use of antipsychotic medications to control the more severe symptoms of terminal delirium. A future study will evaluate the outcome of this enhanced process for the assessment and treatment of terminal delirium in this veteran population.

Acknowledgment

We thank Martin J. Gorbien, MD, associate chief of staff of Geriatrics and Extended Care, for his continued support throughout this project.

Preventable errors by health care workers are widespread and cause significant morbidity and mortality. Wrong site surgery (WSS) is a preventable error that causes harm through both the direct insult of surgery and propagation of the untreated initial problem. WSS also can cause poor patient outcomes, low morale, malpractice claims, and increased costs to the health care system. The estimated median prevalence of WSS across all specialties is 9 events per 1,000,000 surgical procedures, and an institutional study of 112,500 surgical procedures reported 1 wrong-site event, which involved removing the incorrect skin lesion and not removing the intended lesion.^1,2

Though the prevalence is low when examining all specialties together, dermatology is also susceptible to WSS.³ Watson and colleagues demonstrated that 31% of intervention errors were due to WSS and suggested that prebiopsy photography helps decrease errors.⁴ Thus, the American Academy of Dermatology has emphasized the importance of reducing WSS.⁵ A study by Nijhawan and colleagues found that 25% of patients receiving Mohs surgery at a private single cancer center could not identify their biopsy location because the duration between biopsy and surgery allowed biopsy sites to heal well, which made finding the lesion difficult.⁶

Risk factors for WSS include having multiple health care providers (HCPs) living remote from the surgery location involved in the case, being a traveling veteran, receiving care at multiple facilities inside and outside the US Department of Veterans Affairs (VA) system, mislabeling photographs or specimens, and photographs not taken at time of biopsy and too close with no frame of reference to assist in finding the correct site. The VA electronic health record (EHR) is not integrated with outside facility EHRs, and the Office of Community Care (OCC) at the VA is responsible for obtaining copies of outside records. If unsuccessful, the HCP and/or patient must provide the records. Frequently, records are not received or require multiple attempts to be obtained. This mostly affects veterans receiving care at multiple facilities inside and outside the VA system as the lack of or timely receipt of past health records could increase the risk for WSS.

To combat WSS, some institutions have implemented standardized protocols requiring photographic documentation of lesions before biopsy so that the surgeon can properly identify the correct site prior to operating.⁷ Fortunately, recent advances in technology have made it easier to provide photographic documentation of skin lesions. Highsmith and colleagues highlighted use of smartphones to avoid WSS in dermatology.⁷ Despite these advances, photographic documentation of lesions is not universal. A study by Rossy and colleagues found that less than half of patients referred for Mohs surgery had clear documentation of the biopsy site with photography, diagram, or measurements, and of those documented, only a small fraction used photographs.⁸

Photographic documentation is not currently required by the VA, increasing the risk of WSS. About 20% of the ~150 VA dermatology departments nationwide are associated with a dermatology residency program and have implemented photographic documentation of lesions before biopsy. The other 80% of departments may not be using photographic documentation. The following 3 cases experienced by the authors highlight instances of how quality photographic documentation of lesions prior to biopsy can improve patient care and save lives. Then, we propose a photographic documentation protocol for VA dermatology departments to follow based on the photographic standards outlined by the American Society for Dermatologic Surgery.⁹

Case 1 Presentation

A 36-year-old traveling veteran who relocates frequently and receives care at multiple VA medical centers (VAMCs) presented for excision of a melanoma. The patient had been managed at another VAMC where the lesion was biopsied in September 2016. He presented to the Orlando, Florida, VAMC dermatology clinic 5 months later with the photographs of his biopsy sites along with the biopsy reports. The patient had 6 biopsies labeled A through F. Lesion A at the right mid back was positive for melanoma (Figure 1), whereas lesion C on the mid lower back was not cancerous (Figure 2). On examination of the patient’s back, he had numerous moles and scars. The initial receiving HCP circled and photographed the scar presumed to be the melanoma on the mid lower back (Figure 3).

On the day of surgery, the surgeon routinely checked the biopsy report as well as the photograph from the patient’s most recent HCP visit. The surgeon noted that biopsy A (right mid back) on the pathology report had been identified as the melanoma; however, biopsy C (mid lower back) was circled and presumed to be the melanoma in the recent photograph by the receiving HCP—a nurse practitioner. The surgeon compared the initial photos from the referring VAMC with those from the receiving HCP and subsequently matched biopsy A (melanoma) with the correct location on the right mid back.

This discrepancy was explained to the patient with photographic confirmation, allowing for agreement on the correct site before the surgery. The pathology results of the surgical excision confirmed melanoma in the specimen and clear margins. Thus, the correct site was operated on.

Case 2 Presentation

A veteran aged 86 years with a medical history of a double transplant and long-term immunosuppression leading to numerous skin cancers was referred for surgical excision of a confirmed squamous cell carcinoma (SCC) on the left upper back. On the day of surgery, the biopsy site could not be identified clearly due to numerous preexisting scars (Figure 4). No photograph of the original biopsy site was available. The referring HCP was called to the bedside to assist in identifying the biopsy site but also was unable to clearly identify the site. This was explained to the patient. As 2-person confirmation was unsuccessful, conservative treatment was used with patient consent. The patient has since had subsequent close follow-up to monitor for recurrence, as SCC in transplant patients can display aggressive growth and potential for metastasis.

Case 3 Presentation

A veteran was referred for surgical excision of a nonmelanoma skin cancer. The biopsy was completed well in advance of the anticipated surgery day. On the day of surgery, the site could not be detected as it healed well after the biopsy. Although a clinical photograph was available, it was taken too close-up to find a frame of reference for identifying the location of the biopsy site. The referring HCP was called to the bedside to assist in identification of the biopsy site, but 2-person confirmation was unsuccessful. This was explained to the patient, and with his consent, the HCPs agreed on conservative treatment and close follow-up.

Discussion

To prevent and minimize poor outcomes associated with WSS, the health care team should routinely document the lesion location in detail before the biopsy. Many HCPs believe a preoperative photograph is the best method for documentation. As demonstrated in the third case presentation, photographs must be taken at a distance that includes nearby anatomic landmarks for reference. It is suggested that the providers obtain 2 images, one that is far enough to include landmarks, and one that is close enough to clearly differentiate the targeted lesion from others.¹⁰

Although high-resolution digital cameras are preferred, mobile phones also can be used if they provide quality images. As phones with built-in cameras are ubiquitous, they offer a quick and easy method of photographic documentation. St John and colleagues also presented the possibility of having patients keep pictures of the lesion on their phones, as this removes potential privacy concerns and facilitates easy transportation of information between HCPs.¹⁰ If it is discovered that a photograph was not taken at the time of biopsy, our practice contacts the patient and asks them to photograph and circle the biopsy site using their mobile phone or camera and bring it to the surgery appointment. We propose a VA protocol for photographic documentation of biopsy sites (Table).

Conclusions

The cases described here highlight how the lack of proper photographic documentation can prevent the use of curative surgical treatment. In order to reduce WSS and improve quality care, HCPs must continue to take steps and create safeguards to minimize risk. Proper documentation of lesions prior to biopsy provides an effective route to reduce incidence of WSS. If the biopsy site cannot be found, various strategies to properly identify the site can be employed. If WSS occurs, it is important that HCPs provide full disclosure to patients. With a growing emphasis on patient safety measures and advances in technology, HCPs are becoming increasingly cognizant about the most effective ways to optimize patient care, and it is anticipated that this will result in a decrease in morbidity and mortality.

Preventable errors by health care workers are widespread and cause significant morbidity and mortality. Wrong site surgery (WSS) is a preventable error that causes harm through both the direct insult of surgery and propagation of the untreated initial problem. WSS also can cause poor patient outcomes, low morale, malpractice claims, and increased costs to the health care system. The estimated median prevalence of WSS across all specialties is 9 events per 1,000,000 surgical procedures, and an institutional study of 112,500 surgical procedures reported 1 wrong-site event, which involved removing the incorrect skin lesion and not removing the intended lesion.^1,2

Though the prevalence is low when examining all specialties together, dermatology is also susceptible to WSS.³ Watson and colleagues demonstrated that 31% of intervention errors were due to WSS and suggested that prebiopsy photography helps decrease errors.⁴ Thus, the American Academy of Dermatology has emphasized the importance of reducing WSS.⁵ A study by Nijhawan and colleagues found that 25% of patients receiving Mohs surgery at a private single cancer center could not identify their biopsy location because the duration between biopsy and surgery allowed biopsy sites to heal well, which made finding the lesion difficult.⁶

Risk factors for WSS include having multiple health care providers (HCPs) living remote from the surgery location involved in the case, being a traveling veteran, receiving care at multiple facilities inside and outside the US Department of Veterans Affairs (VA) system, mislabeling photographs or specimens, and photographs not taken at time of biopsy and too close with no frame of reference to assist in finding the correct site. The VA electronic health record (EHR) is not integrated with outside facility EHRs, and the Office of Community Care (OCC) at the VA is responsible for obtaining copies of outside records. If unsuccessful, the HCP and/or patient must provide the records. Frequently, records are not received or require multiple attempts to be obtained. This mostly affects veterans receiving care at multiple facilities inside and outside the VA system as the lack of or timely receipt of past health records could increase the risk for WSS.

To combat WSS, some institutions have implemented standardized protocols requiring photographic documentation of lesions before biopsy so that the surgeon can properly identify the correct site prior to operating.⁷ Fortunately, recent advances in technology have made it easier to provide photographic documentation of skin lesions. Highsmith and colleagues highlighted use of smartphones to avoid WSS in dermatology.⁷ Despite these advances, photographic documentation of lesions is not universal. A study by Rossy and colleagues found that less than half of patients referred for Mohs surgery had clear documentation of the biopsy site with photography, diagram, or measurements, and of those documented, only a small fraction used photographs.⁸

Photographic documentation is not currently required by the VA, increasing the risk of WSS. About 20% of the ~150 VA dermatology departments nationwide are associated with a dermatology residency program and have implemented photographic documentation of lesions before biopsy. The other 80% of departments may not be using photographic documentation. The following 3 cases experienced by the authors highlight instances of how quality photographic documentation of lesions prior to biopsy can improve patient care and save lives. Then, we propose a photographic documentation protocol for VA dermatology departments to follow based on the photographic standards outlined by the American Society for Dermatologic Surgery.⁹

Case 1 Presentation

A 36-year-old traveling veteran who relocates frequently and receives care at multiple VA medical centers (VAMCs) presented for excision of a melanoma. The patient had been managed at another VAMC where the lesion was biopsied in September 2016. He presented to the Orlando, Florida, VAMC dermatology clinic 5 months later with the photographs of his biopsy sites along with the biopsy reports. The patient had 6 biopsies labeled A through F. Lesion A at the right mid back was positive for melanoma (Figure 1), whereas lesion C on the mid lower back was not cancerous (Figure 2). On examination of the patient’s back, he had numerous moles and scars. The initial receiving HCP circled and photographed the scar presumed to be the melanoma on the mid lower back (Figure 3).

On the day of surgery, the surgeon routinely checked the biopsy report as well as the photograph from the patient’s most recent HCP visit. The surgeon noted that biopsy A (right mid back) on the pathology report had been identified as the melanoma; however, biopsy C (mid lower back) was circled and presumed to be the melanoma in the recent photograph by the receiving HCP—a nurse practitioner. The surgeon compared the initial photos from the referring VAMC with those from the receiving HCP and subsequently matched biopsy A (melanoma) with the correct location on the right mid back.

This discrepancy was explained to the patient with photographic confirmation, allowing for agreement on the correct site before the surgery. The pathology results of the surgical excision confirmed melanoma in the specimen and clear margins. Thus, the correct site was operated on.

Case 2 Presentation

A veteran aged 86 years with a medical history of a double transplant and long-term immunosuppression leading to numerous skin cancers was referred for surgical excision of a confirmed squamous cell carcinoma (SCC) on the left upper back. On the day of surgery, the biopsy site could not be identified clearly due to numerous preexisting scars (Figure 4). No photograph of the original biopsy site was available. The referring HCP was called to the bedside to assist in identifying the biopsy site but also was unable to clearly identify the site. This was explained to the patient. As 2-person confirmation was unsuccessful, conservative treatment was used with patient consent. The patient has since had subsequent close follow-up to monitor for recurrence, as SCC in transplant patients can display aggressive growth and potential for metastasis.

Case 3 Presentation

A veteran was referred for surgical excision of a nonmelanoma skin cancer. The biopsy was completed well in advance of the anticipated surgery day. On the day of surgery, the site could not be detected as it healed well after the biopsy. Although a clinical photograph was available, it was taken too close-up to find a frame of reference for identifying the location of the biopsy site. The referring HCP was called to the bedside to assist in identification of the biopsy site, but 2-person confirmation was unsuccessful. This was explained to the patient, and with his consent, the HCPs agreed on conservative treatment and close follow-up.

Discussion

To prevent and minimize poor outcomes associated with WSS, the health care team should routinely document the lesion location in detail before the biopsy. Many HCPs believe a preoperative photograph is the best method for documentation. As demonstrated in the third case presentation, photographs must be taken at a distance that includes nearby anatomic landmarks for reference. It is suggested that the providers obtain 2 images, one that is far enough to include landmarks, and one that is close enough to clearly differentiate the targeted lesion from others.¹⁰

Although high-resolution digital cameras are preferred, mobile phones also can be used if they provide quality images. As phones with built-in cameras are ubiquitous, they offer a quick and easy method of photographic documentation. St John and colleagues also presented the possibility of having patients keep pictures of the lesion on their phones, as this removes potential privacy concerns and facilitates easy transportation of information between HCPs.¹⁰ If it is discovered that a photograph was not taken at the time of biopsy, our practice contacts the patient and asks them to photograph and circle the biopsy site using their mobile phone or camera and bring it to the surgery appointment. We propose a VA protocol for photographic documentation of biopsy sites (Table).

Conclusions

The cases described here highlight how the lack of proper photographic documentation can prevent the use of curative surgical treatment. In order to reduce WSS and improve quality care, HCPs must continue to take steps and create safeguards to minimize risk. Proper documentation of lesions prior to biopsy provides an effective route to reduce incidence of WSS. If the biopsy site cannot be found, various strategies to properly identify the site can be employed. If WSS occurs, it is important that HCPs provide full disclosure to patients. With a growing emphasis on patient safety measures and advances in technology, HCPs are becoming increasingly cognizant about the most effective ways to optimize patient care, and it is anticipated that this will result in a decrease in morbidity and mortality.

Preventable errors by health care workers are widespread and cause significant morbidity and mortality. Wrong site surgery (WSS) is a preventable error that causes harm through both the direct insult of surgery and propagation of the untreated initial problem. WSS also can cause poor patient outcomes, low morale, malpractice claims, and increased costs to the health care system. The estimated median prevalence of WSS across all specialties is 9 events per 1,000,000 surgical procedures, and an institutional study of 112,500 surgical procedures reported 1 wrong-site event, which involved removing the incorrect skin lesion and not removing the intended lesion.^1,2

Though the prevalence is low when examining all specialties together, dermatology is also susceptible to WSS.³ Watson and colleagues demonstrated that 31% of intervention errors were due to WSS and suggested that prebiopsy photography helps decrease errors.⁴ Thus, the American Academy of Dermatology has emphasized the importance of reducing WSS.⁵ A study by Nijhawan and colleagues found that 25% of patients receiving Mohs surgery at a private single cancer center could not identify their biopsy location because the duration between biopsy and surgery allowed biopsy sites to heal well, which made finding the lesion difficult.⁶

Risk factors for WSS include having multiple health care providers (HCPs) living remote from the surgery location involved in the case, being a traveling veteran, receiving care at multiple facilities inside and outside the US Department of Veterans Affairs (VA) system, mislabeling photographs or specimens, and photographs not taken at time of biopsy and too close with no frame of reference to assist in finding the correct site. The VA electronic health record (EHR) is not integrated with outside facility EHRs, and the Office of Community Care (OCC) at the VA is responsible for obtaining copies of outside records. If unsuccessful, the HCP and/or patient must provide the records. Frequently, records are not received or require multiple attempts to be obtained. This mostly affects veterans receiving care at multiple facilities inside and outside the VA system as the lack of or timely receipt of past health records could increase the risk for WSS.

To combat WSS, some institutions have implemented standardized protocols requiring photographic documentation of lesions before biopsy so that the surgeon can properly identify the correct site prior to operating.⁷ Fortunately, recent advances in technology have made it easier to provide photographic documentation of skin lesions. Highsmith and colleagues highlighted use of smartphones to avoid WSS in dermatology.⁷ Despite these advances, photographic documentation of lesions is not universal. A study by Rossy and colleagues found that less than half of patients referred for Mohs surgery had clear documentation of the biopsy site with photography, diagram, or measurements, and of those documented, only a small fraction used photographs.⁸

Photographic documentation is not currently required by the VA, increasing the risk of WSS. About 20% of the ~150 VA dermatology departments nationwide are associated with a dermatology residency program and have implemented photographic documentation of lesions before biopsy. The other 80% of departments may not be using photographic documentation. The following 3 cases experienced by the authors highlight instances of how quality photographic documentation of lesions prior to biopsy can improve patient care and save lives. Then, we propose a photographic documentation protocol for VA dermatology departments to follow based on the photographic standards outlined by the American Society for Dermatologic Surgery.⁹

Case 1 Presentation

A 36-year-old traveling veteran who relocates frequently and receives care at multiple VA medical centers (VAMCs) presented for excision of a melanoma. The patient had been managed at another VAMC where the lesion was biopsied in September 2016. He presented to the Orlando, Florida, VAMC dermatology clinic 5 months later with the photographs of his biopsy sites along with the biopsy reports. The patient had 6 biopsies labeled A through F. Lesion A at the right mid back was positive for melanoma (Figure 1), whereas lesion C on the mid lower back was not cancerous (Figure 2). On examination of the patient’s back, he had numerous moles and scars. The initial receiving HCP circled and photographed the scar presumed to be the melanoma on the mid lower back (Figure 3).

On the day of surgery, the surgeon routinely checked the biopsy report as well as the photograph from the patient’s most recent HCP visit. The surgeon noted that biopsy A (right mid back) on the pathology report had been identified as the melanoma; however, biopsy C (mid lower back) was circled and presumed to be the melanoma in the recent photograph by the receiving HCP—a nurse practitioner. The surgeon compared the initial photos from the referring VAMC with those from the receiving HCP and subsequently matched biopsy A (melanoma) with the correct location on the right mid back.

This discrepancy was explained to the patient with photographic confirmation, allowing for agreement on the correct site before the surgery. The pathology results of the surgical excision confirmed melanoma in the specimen and clear margins. Thus, the correct site was operated on.

Case 2 Presentation

A veteran aged 86 years with a medical history of a double transplant and long-term immunosuppression leading to numerous skin cancers was referred for surgical excision of a confirmed squamous cell carcinoma (SCC) on the left upper back. On the day of surgery, the biopsy site could not be identified clearly due to numerous preexisting scars (Figure 4). No photograph of the original biopsy site was available. The referring HCP was called to the bedside to assist in identifying the biopsy site but also was unable to clearly identify the site. This was explained to the patient. As 2-person confirmation was unsuccessful, conservative treatment was used with patient consent. The patient has since had subsequent close follow-up to monitor for recurrence, as SCC in transplant patients can display aggressive growth and potential for metastasis.

Case 3 Presentation

A veteran was referred for surgical excision of a nonmelanoma skin cancer. The biopsy was completed well in advance of the anticipated surgery day. On the day of surgery, the site could not be detected as it healed well after the biopsy. Although a clinical photograph was available, it was taken too close-up to find a frame of reference for identifying the location of the biopsy site. The referring HCP was called to the bedside to assist in identification of the biopsy site, but 2-person confirmation was unsuccessful. This was explained to the patient, and with his consent, the HCPs agreed on conservative treatment and close follow-up.

Discussion

To prevent and minimize poor outcomes associated with WSS, the health care team should routinely document the lesion location in detail before the biopsy. Many HCPs believe a preoperative photograph is the best method for documentation. As demonstrated in the third case presentation, photographs must be taken at a distance that includes nearby anatomic landmarks for reference. It is suggested that the providers obtain 2 images, one that is far enough to include landmarks, and one that is close enough to clearly differentiate the targeted lesion from others.¹⁰

Although high-resolution digital cameras are preferred, mobile phones also can be used if they provide quality images. As phones with built-in cameras are ubiquitous, they offer a quick and easy method of photographic documentation. St John and colleagues also presented the possibility of having patients keep pictures of the lesion on their phones, as this removes potential privacy concerns and facilitates easy transportation of information between HCPs.¹⁰ If it is discovered that a photograph was not taken at the time of biopsy, our practice contacts the patient and asks them to photograph and circle the biopsy site using their mobile phone or camera and bring it to the surgery appointment. We propose a VA protocol for photographic documentation of biopsy sites (Table).

Conclusions

The cases described here highlight how the lack of proper photographic documentation can prevent the use of curative surgical treatment. In order to reduce WSS and improve quality care, HCPs must continue to take steps and create safeguards to minimize risk. Proper documentation of lesions prior to biopsy provides an effective route to reduce incidence of WSS. If the biopsy site cannot be found, various strategies to properly identify the site can be employed. If WSS occurs, it is important that HCPs provide full disclosure to patients. With a growing emphasis on patient safety measures and advances in technology, HCPs are becoming increasingly cognizant about the most effective ways to optimize patient care, and it is anticipated that this will result in a decrease in morbidity and mortality.

SARS-CoV-2 seroprevalence studies of healthcare workers (HCWs) provide valuable insights into the excess risk of infection in this population and indirect evidence supporting the value of personal protective equipment (PPE) use. Seroprevalence estimates are composite measures of exposure risk and transmission mitigation both in the healthcare and community environments. The challenge of interpreting these studies arises from the diversity of HCW vocational roles and work settings in juxtaposition to heterogeneous community exposure risks. In this issue, two studies untangle some of these competing factors.

Investigators from Kashmir, India, assessed the relationship between seropositivity and specific HCW roles and work sites.¹ They found a lower seroprevalence among HCWs at hospitals dedicated to COVID patients, relative to non-COVID hospitals. This seemingly paradoxical finding likely results from a combination of vigilant PPE adherence enforced through a buddy system, restrictive visitation policies, HCW residential dormitories reducing community exposure, and a spillover effect of careful in-hospital exposure avoidance practices on out-of-hospital behavior. A similar spillover effect has been hypothesized for low HCW seroprevalence relative to the surrounding community in California.²

In complement, researchers at a large New York City (NYC) hospital found higher overall HCW seropositivity rates compared with the community, though estimates were strikingly variable after detailed stratification by job function and location.³ The gradient of seroprevalence showed the highest risk among nurses and those in nonclinical, low-wage jobs (eg, patient transport, housekeeping), a finding also seen in another US study prior to adjustment for demographic and community factors.⁴ This finding highlights the association between socioeconomic status, structural community exposure risk factors such as multiple essential workers living within multigenerational households, and the challenges of sickness absenteeism. High seroprevalence among nurses and emergency department HCWs (who expeditiously evaluate many undifferentiated patients) may reflect both greater aggregate duration of exposure to infected patients and increased frequency of PPE donning and doffing, resulting in fatigue and diminished vigilance.⁵

A NYC-based study similarly showed high HCW seroprevalence, although no consistent associations with job function (albeit measured with less granularity) or community-based exposures were identified.⁶ Several studies comparing HCW to local community seropositivity rates have reached disparate conclusions.^2,7 These contrasting data may result from variability in vigilance of PPE use, mask use in work rooms or during meals/breaktimes, sick leave policies driven by staffing demands, and neighborhood factors. In addition, selection biases and timing of blood sampling relative to viral transmission peaks (with differing degrees of temporal antibody waning) may contribute to the apparent discordance. In particular, comparative community-based samples vary greatly in their inclusion of asymptomatic patients, which can substantially affect such estimates by changing the denominator population.

We draw three conclusions: (1) Evidence for HCW exposure often tracks with community infection rates, suggesting that nonworkplace exposures are a dominant source of HCW seropositivity; (2) vigilant PPE use and assertively implemented protective measures unrelated to patient encounters can dramatically reduce infection risk, even among those with frequent exposures; and (3) HCW infection risk during future peaks can be effectively restrained with adequate resources and support, even in the presence of variants for which no effective vaccination or preventive pharmacotherapy exists. Given the divergent seroprevalence rates found in these studies after detailed stratification by job function and location, it is important for future studies to evaluate their relationship with infectious risk. Accurately quantifying the excess risks borne by HCWs may remain an elusive objective, but experiential knowledge offers numerous strategies worthy of proactive implementation to preserve HCW safety and well-being.

SARS-CoV-2 seroprevalence studies of healthcare workers (HCWs) provide valuable insights into the excess risk of infection in this population and indirect evidence supporting the value of personal protective equipment (PPE) use. Seroprevalence estimates are composite measures of exposure risk and transmission mitigation both in the healthcare and community environments. The challenge of interpreting these studies arises from the diversity of HCW vocational roles and work settings in juxtaposition to heterogeneous community exposure risks. In this issue, two studies untangle some of these competing factors.

Investigators from Kashmir, India, assessed the relationship between seropositivity and specific HCW roles and work sites.¹ They found a lower seroprevalence among HCWs at hospitals dedicated to COVID patients, relative to non-COVID hospitals. This seemingly paradoxical finding likely results from a combination of vigilant PPE adherence enforced through a buddy system, restrictive visitation policies, HCW residential dormitories reducing community exposure, and a spillover effect of careful in-hospital exposure avoidance practices on out-of-hospital behavior. A similar spillover effect has been hypothesized for low HCW seroprevalence relative to the surrounding community in California.²

In complement, researchers at a large New York City (NYC) hospital found higher overall HCW seropositivity rates compared with the community, though estimates were strikingly variable after detailed stratification by job function and location.³ The gradient of seroprevalence showed the highest risk among nurses and those in nonclinical, low-wage jobs (eg, patient transport, housekeeping), a finding also seen in another US study prior to adjustment for demographic and community factors.⁴ This finding highlights the association between socioeconomic status, structural community exposure risk factors such as multiple essential workers living within multigenerational households, and the challenges of sickness absenteeism. High seroprevalence among nurses and emergency department HCWs (who expeditiously evaluate many undifferentiated patients) may reflect both greater aggregate duration of exposure to infected patients and increased frequency of PPE donning and doffing, resulting in fatigue and diminished vigilance.⁵

A NYC-based study similarly showed high HCW seroprevalence, although no consistent associations with job function (albeit measured with less granularity) or community-based exposures were identified.⁶ Several studies comparing HCW to local community seropositivity rates have reached disparate conclusions.^2,7 These contrasting data may result from variability in vigilance of PPE use, mask use in work rooms or during meals/breaktimes, sick leave policies driven by staffing demands, and neighborhood factors. In addition, selection biases and timing of blood sampling relative to viral transmission peaks (with differing degrees of temporal antibody waning) may contribute to the apparent discordance. In particular, comparative community-based samples vary greatly in their inclusion of asymptomatic patients, which can substantially affect such estimates by changing the denominator population.

We draw three conclusions: (1) Evidence for HCW exposure often tracks with community infection rates, suggesting that nonworkplace exposures are a dominant source of HCW seropositivity; (2) vigilant PPE use and assertively implemented protective measures unrelated to patient encounters can dramatically reduce infection risk, even among those with frequent exposures; and (3) HCW infection risk during future peaks can be effectively restrained with adequate resources and support, even in the presence of variants for which no effective vaccination or preventive pharmacotherapy exists. Given the divergent seroprevalence rates found in these studies after detailed stratification by job function and location, it is important for future studies to evaluate their relationship with infectious risk. Accurately quantifying the excess risks borne by HCWs may remain an elusive objective, but experiential knowledge offers numerous strategies worthy of proactive implementation to preserve HCW safety and well-being.

SARS-CoV-2 seroprevalence studies of healthcare workers (HCWs) provide valuable insights into the excess risk of infection in this population and indirect evidence supporting the value of personal protective equipment (PPE) use. Seroprevalence estimates are composite measures of exposure risk and transmission mitigation both in the healthcare and community environments. The challenge of interpreting these studies arises from the diversity of HCW vocational roles and work settings in juxtaposition to heterogeneous community exposure risks. In this issue, two studies untangle some of these competing factors.

Investigators from Kashmir, India, assessed the relationship between seropositivity and specific HCW roles and work sites.¹ They found a lower seroprevalence among HCWs at hospitals dedicated to COVID patients, relative to non-COVID hospitals. This seemingly paradoxical finding likely results from a combination of vigilant PPE adherence enforced through a buddy system, restrictive visitation policies, HCW residential dormitories reducing community exposure, and a spillover effect of careful in-hospital exposure avoidance practices on out-of-hospital behavior. A similar spillover effect has been hypothesized for low HCW seroprevalence relative to the surrounding community in California.²

In complement, researchers at a large New York City (NYC) hospital found higher overall HCW seropositivity rates compared with the community, though estimates were strikingly variable after detailed stratification by job function and location.³ The gradient of seroprevalence showed the highest risk among nurses and those in nonclinical, low-wage jobs (eg, patient transport, housekeeping), a finding also seen in another US study prior to adjustment for demographic and community factors.⁴ This finding highlights the association between socioeconomic status, structural community exposure risk factors such as multiple essential workers living within multigenerational households, and the challenges of sickness absenteeism. High seroprevalence among nurses and emergency department HCWs (who expeditiously evaluate many undifferentiated patients) may reflect both greater aggregate duration of exposure to infected patients and increased frequency of PPE donning and doffing, resulting in fatigue and diminished vigilance.⁵

A NYC-based study similarly showed high HCW seroprevalence, although no consistent associations with job function (albeit measured with less granularity) or community-based exposures were identified.⁶ Several studies comparing HCW to local community seropositivity rates have reached disparate conclusions.^2,7 These contrasting data may result from variability in vigilance of PPE use, mask use in work rooms or during meals/breaktimes, sick leave policies driven by staffing demands, and neighborhood factors. In addition, selection biases and timing of blood sampling relative to viral transmission peaks (with differing degrees of temporal antibody waning) may contribute to the apparent discordance. In particular, comparative community-based samples vary greatly in their inclusion of asymptomatic patients, which can substantially affect such estimates by changing the denominator population.

We draw three conclusions: (1) Evidence for HCW exposure often tracks with community infection rates, suggesting that nonworkplace exposures are a dominant source of HCW seropositivity; (2) vigilant PPE use and assertively implemented protective measures unrelated to patient encounters can dramatically reduce infection risk, even among those with frequent exposures; and (3) HCW infection risk during future peaks can be effectively restrained with adequate resources and support, even in the presence of variants for which no effective vaccination or preventive pharmacotherapy exists. Given the divergent seroprevalence rates found in these studies after detailed stratification by job function and location, it is important for future studies to evaluate their relationship with infectious risk. Accurately quantifying the excess risks borne by HCWs may remain an elusive objective, but experiential knowledge offers numerous strategies worthy of proactive implementation to preserve HCW safety and well-being.

Bronchiolitis, the most common cause of hospital admission for infants, is responsible for more than $500 million in direct medical costs in the United States yearly. Recent efforts have focused on what can be safely avoided when caring for patients with bronchiolitis (eg, continuous pulse oximetry, bronchodilator administration). While there remains substantial room for improvement in avoiding such low-value (or no-value) practices, the incremental improvements from these de-escalations will reach an asymptote over time. Further improvements in care and value must occur by doing things differently—not just simply doing less.

In this month’s Journal of Hospital Medicine, Ohlsen et al¹ describe an intervention to decrease length of stay (LOS) for patients with bronchiolitis They employed an interrupted time series analysis to evaluate implementation of an observation unit and home oxygen therapy (OU-HOT) model of care and found that LOS dramatically decreased immediately following implementation. This reduction was maintained over 9 years. Use of home oxygen decreased over the study period, while LOS remained low, suggesting that the most important intervention was a structural one—the admission of patients to a unit dedicated to efficient discharge.

Observation units, staffed 24/7 with attending physicians, are well adapted to care for patients with illnesses like bronchiolitis, where hospitalization, though often needed, may be brief.² These units are designed more like an emergency department than an inpatient unit, with protocolized care and the expectation of rapid turnover.

Multiple studies have shown that physician-related delays are a primary driver of delayed discharge from inpatient units. Such delays include delayed or variable clinical decision-making, inadequate communication of discharge criteria, and waiting to staff patients with an attending physician.^3-5 Addressing these issues could allow inpatient units to function more like observation units for specific diagnoses. Standardization of care around specific diagnoses can make decision-making and discharge more efficient. In 2014, White et al⁴ showed that standardizing discharge criteria for specific diagnoses (including bronchiolitis) and embedding these criteria in admission order sets resulted in a significant decrease in LOS without affecting readmission rates or patient satisfaction.

To address the issues of attending availability, we may need to rethink rounding. The daily structure of inpatient rounding has not meaningfully changed since the 1950s. While there has been a push for increased morning discharges, this approach misses many patients whose illness course is evolving and who may be ready for discharge in the afternoon or evening.⁶ The current structure of morning rounds on medical teams is based on the need for resident education, supervision, and time available for attendings to complete administrative tasks and teaching in the afternoons. Structural change in patient care requires academic institutions to rethink what “being on service” actually means. Since LOS in these cases is brief, multiple days of clinical continuity may not be as beneficial as with other diagnoses. Further, there is no reason that daytime rounding teams are the only teams that can discharge patients. Telemedicine could also offer an opportunity for attending physicians to remotely determine whether a patient is discharge appropriate. Standardization of discharge criteria at admission could allow for trainees to discharge patients when they meet those criteria.

Perhaps we should begin to adapt our work structure to our patients’ needs, rather than the other way around. In pediatrics, we have already made traditional rounding more patient-focused through the practice of family-centered rounding. We should identify, as the authors have, ways to do things differently to make further improvements in care.

Ultimately, the success of this OU-HOT protocol demonstrates the power of structural interventions aimed at changing how we do things rather than just doing more (or less) of the same.

Bronchiolitis, the most common cause of hospital admission for infants, is responsible for more than $500 million in direct medical costs in the United States yearly. Recent efforts have focused on what can be safely avoided when caring for patients with bronchiolitis (eg, continuous pulse oximetry, bronchodilator administration). While there remains substantial room for improvement in avoiding such low-value (or no-value) practices, the incremental improvements from these de-escalations will reach an asymptote over time. Further improvements in care and value must occur by doing things differently—not just simply doing less.

In this month’s Journal of Hospital Medicine, Ohlsen et al¹ describe an intervention to decrease length of stay (LOS) for patients with bronchiolitis They employed an interrupted time series analysis to evaluate implementation of an observation unit and home oxygen therapy (OU-HOT) model of care and found that LOS dramatically decreased immediately following implementation. This reduction was maintained over 9 years. Use of home oxygen decreased over the study period, while LOS remained low, suggesting that the most important intervention was a structural one—the admission of patients to a unit dedicated to efficient discharge.

Observation units, staffed 24/7 with attending physicians, are well adapted to care for patients with illnesses like bronchiolitis, where hospitalization, though often needed, may be brief.² These units are designed more like an emergency department than an inpatient unit, with protocolized care and the expectation of rapid turnover.

Multiple studies have shown that physician-related delays are a primary driver of delayed discharge from inpatient units. Such delays include delayed or variable clinical decision-making, inadequate communication of discharge criteria, and waiting to staff patients with an attending physician.^3-5 Addressing these issues could allow inpatient units to function more like observation units for specific diagnoses. Standardization of care around specific diagnoses can make decision-making and discharge more efficient. In 2014, White et al⁴ showed that standardizing discharge criteria for specific diagnoses (including bronchiolitis) and embedding these criteria in admission order sets resulted in a significant decrease in LOS without affecting readmission rates or patient satisfaction.

To address the issues of attending availability, we may need to rethink rounding. The daily structure of inpatient rounding has not meaningfully changed since the 1950s. While there has been a push for increased morning discharges, this approach misses many patients whose illness course is evolving and who may be ready for discharge in the afternoon or evening.⁶ The current structure of morning rounds on medical teams is based on the need for resident education, supervision, and time available for attendings to complete administrative tasks and teaching in the afternoons. Structural change in patient care requires academic institutions to rethink what “being on service” actually means. Since LOS in these cases is brief, multiple days of clinical continuity may not be as beneficial as with other diagnoses. Further, there is no reason that daytime rounding teams are the only teams that can discharge patients. Telemedicine could also offer an opportunity for attending physicians to remotely determine whether a patient is discharge appropriate. Standardization of discharge criteria at admission could allow for trainees to discharge patients when they meet those criteria.

Perhaps we should begin to adapt our work structure to our patients’ needs, rather than the other way around. In pediatrics, we have already made traditional rounding more patient-focused through the practice of family-centered rounding. We should identify, as the authors have, ways to do things differently to make further improvements in care.

Ultimately, the success of this OU-HOT protocol demonstrates the power of structural interventions aimed at changing how we do things rather than just doing more (or less) of the same.

Bronchiolitis, the most common cause of hospital admission for infants, is responsible for more than $500 million in direct medical costs in the United States yearly. Recent efforts have focused on what can be safely avoided when caring for patients with bronchiolitis (eg, continuous pulse oximetry, bronchodilator administration). While there remains substantial room for improvement in avoiding such low-value (or no-value) practices, the incremental improvements from these de-escalations will reach an asymptote over time. Further improvements in care and value must occur by doing things differently—not just simply doing less.

In this month’s Journal of Hospital Medicine, Ohlsen et al¹ describe an intervention to decrease length of stay (LOS) for patients with bronchiolitis They employed an interrupted time series analysis to evaluate implementation of an observation unit and home oxygen therapy (OU-HOT) model of care and found that LOS dramatically decreased immediately following implementation. This reduction was maintained over 9 years. Use of home oxygen decreased over the study period, while LOS remained low, suggesting that the most important intervention was a structural one—the admission of patients to a unit dedicated to efficient discharge.

Observation units, staffed 24/7 with attending physicians, are well adapted to care for patients with illnesses like bronchiolitis, where hospitalization, though often needed, may be brief.² These units are designed more like an emergency department than an inpatient unit, with protocolized care and the expectation of rapid turnover.

Multiple studies have shown that physician-related delays are a primary driver of delayed discharge from inpatient units. Such delays include delayed or variable clinical decision-making, inadequate communication of discharge criteria, and waiting to staff patients with an attending physician.^3-5 Addressing these issues could allow inpatient units to function more like observation units for specific diagnoses. Standardization of care around specific diagnoses can make decision-making and discharge more efficient. In 2014, White et al⁴ showed that standardizing discharge criteria for specific diagnoses (including bronchiolitis) and embedding these criteria in admission order sets resulted in a significant decrease in LOS without affecting readmission rates or patient satisfaction.

To address the issues of attending availability, we may need to rethink rounding. The daily structure of inpatient rounding has not meaningfully changed since the 1950s. While there has been a push for increased morning discharges, this approach misses many patients whose illness course is evolving and who may be ready for discharge in the afternoon or evening.⁶ The current structure of morning rounds on medical teams is based on the need for resident education, supervision, and time available for attendings to complete administrative tasks and teaching in the afternoons. Structural change in patient care requires academic institutions to rethink what “being on service” actually means. Since LOS in these cases is brief, multiple days of clinical continuity may not be as beneficial as with other diagnoses. Further, there is no reason that daytime rounding teams are the only teams that can discharge patients. Telemedicine could also offer an opportunity for attending physicians to remotely determine whether a patient is discharge appropriate. Standardization of discharge criteria at admission could allow for trainees to discharge patients when they meet those criteria.

Perhaps we should begin to adapt our work structure to our patients’ needs, rather than the other way around. In pediatrics, we have already made traditional rounding more patient-focused through the practice of family-centered rounding. We should identify, as the authors have, ways to do things differently to make further improvements in care.

Ultimately, the success of this OU-HOT protocol demonstrates the power of structural interventions aimed at changing how we do things rather than just doing more (or less) of the same.

”Good evening,“ said the little prince politely.

”Good evening,“ said the snake.

”What planet have I fallen on?“ asked the little prince.

”On the planet Earth, in Africa,“ replied the snake.

”Oh… Then there are no people on Earth?”

”This is the desert. There are no people in the desert. The Earth is big,“ said the snake.

The little prince sat down on a stone and looked up at the sky.

”I wonder,“ he said, “if the stars are lit up so that each of us can find his own star again. Look at my planet. It is right above us… But how far away is it?” ¹

Le Petit Prince is one of the twentieth century’s most widely read fables.¹ Written in 1943 by the French aviator and novelist Antoine de Saint-Exupéry, it tells the story of a young prince who inhabits a small planet in outer space with his muse, a fragile and dainty rose. The prince loves his rose and goes to great lengths to protect her, but her constant needs prove too much for him to bear. One day he decides to leave her and sets out on a journey across the universe. Along the way he stops at several different planets and interacts with their sole inhabitants, each of whom performs a bizarre and arguably pointless activity. The prince leaves each planet confused and despondent—for no place or person has proven more inspiring than his own planet or rose—until he arrives on Earth, where he meets a snake, a fox, and the novel’s unnamed narrator. Their company is a welcome relief for the travel-weary prince, who learns important lessons about love, friendship, and “matters of consequence.” Toward the novel’s end, the snake promises to deliver the little prince home if he allows himself to be bitten. The prince obliges in order to be with his rose, and he soon disappears. The story concludes with the narrator looking up at the stars, wondering if the prince is somewhere among them.

One interpretation of Le Petit Prince is that life is more beautiful when the things that give it meaning are recognized and cherished, but there is a heavy irony behind this theme. The story was published during one of the lowest points in the Second World War, when France was still in the grips of its German oppressors. Saint-Exupéry himself had fled to the United States years earlier and composed Le Petit Prince during a time of personal upheaval. In short, nothing about the context of the book’s birth seemed to inspire its rosy message.   

Now, almost 80 years after the first publication of Le Petit Prince, we find ourselves in a similarly jarring and unpredictable time. As calamitous global events unfold around us, it is difficult not to feel overwhelmed. For healthcare workers, the crush of patient care has made us feel vulnerable—first to a virus that might infect us and our loved ones, and second, to the overwhelming sense of despair when caring for patients who ultimately die despite our best efforts. Pandemics are a time of physical and social disruption, and while it has been 100 years since we experienced one like this, they are a repeated part of the history of life on our planet. What would the little prince see if he landed in our clinics, hospitals, nursing homes, testing centers, or vaccination facilities today? Would he observe patients saying good-bye to family members on tablets and cell phones because their loved ones are not allowed to visit in person? Would he see healthcare workers struggling to resuscitate dying patients in a crowded emergency department or intensive care unit? Would he see long lines of cars filled with people waiting for tests or vaccines? Would he see government officials and public health workers agonizing over decisions about steps that could reduce spread but impose economic hardship on many?

There has been much debate about whether Le Petit Prince is a children’s story or a message for adults disguised as a children’s fable. Perhaps the answer is that it is both, for many children’s stories were actually written for adults. Despite the fragility and delicacy of the book, there is clearly a haunting and deep irony inherent in what it is, in effect, a most savage critique of the world at war.

Two themes that emerge in the novel resonate widely now: isolation and death. Each character the little prince meets is alone, mirroring the long periods of social distancing we have experienced over the past year. And while death is never explicitly mentioned in the book, it seems to be lurking throughout, especially when the prince disappears from Earth after being bitten by the snake. Currently, we have almost become numb to the reported daily death counts—each one alone would have evoked outrage in more usual times. One might imagine that Saint-Exupéry wrote this fable in part to help people cope with the deaths of their loved ones.

And when you are comforted (time soothes all sorrows) you will be happy to have known me. You will always be my friend. You will want to laugh with me. And from time to time you will open your window, so, just for the pleasure of it ... And your friends will be astonished to see you laughing whilst gazing at the sky! And so you will say to them, “Yes, stars always make me laugh!”

Over the past year, both authors of this essay have seen people turn to Le Petit Prince to cope with death. One of us observed a daughter reading the book to her mother at her intensive care bedside on the day she died. The other received a copy as thanks from the wife of a young man who died after 18 months of punishing chemotherapy for sarcoma. Inside the cover was a picture of her husband and the inscription, “Please share this book with someone you love—it’s meant to be read out loud—and remember James.” And so I did, with my grandson Sebastian, who listened to the story with the imagination, wonder, and curiosity of a 6-year-old—he had many questions.

Perhaps the fable that has comforted our patients and their families during their time of despair can do the same for us. Like the prince, who returns to his rose after a difficult journey, we might find solace in the people and things that give our lives their deepest meaning. Thereafter, we might return, rejuvenated, to the clinics, emergency departments, and inpatient wards where our daily work must continue. While the scale of the problems around us makes it feel like any step we take towards preserving our hope will be moot, Le Petit Prince teaches us there is value in making the effort. And there is even a chance that we will find, to our surprise, and against our more cynical judgment, a small rose pushing itself up towards the light.  

The authors thank Rita Charon (Columbia University), Pam Hartzband (Harvard University), Raphael Rush (University of Toronto), and Emily Silverman (University of California San Francisco) for their comments on earlier versions of this essay. None were compensated. We thank Sebastian, James’ wife, and our other patient’s daughter for giving permission to include them in the story.

”Good evening,“ said the little prince politely.

”Good evening,“ said the snake.

”What planet have I fallen on?“ asked the little prince.

”On the planet Earth, in Africa,“ replied the snake.

”Oh… Then there are no people on Earth?”

”This is the desert. There are no people in the desert. The Earth is big,“ said the snake.

The little prince sat down on a stone and looked up at the sky.

”I wonder,“ he said, “if the stars are lit up so that each of us can find his own star again. Look at my planet. It is right above us… But how far away is it?” ¹

Le Petit Prince is one of the twentieth century’s most widely read fables.¹ Written in 1943 by the French aviator and novelist Antoine de Saint-Exupéry, it tells the story of a young prince who inhabits a small planet in outer space with his muse, a fragile and dainty rose. The prince loves his rose and goes to great lengths to protect her, but her constant needs prove too much for him to bear. One day he decides to leave her and sets out on a journey across the universe. Along the way he stops at several different planets and interacts with their sole inhabitants, each of whom performs a bizarre and arguably pointless activity. The prince leaves each planet confused and despondent—for no place or person has proven more inspiring than his own planet or rose—until he arrives on Earth, where he meets a snake, a fox, and the novel’s unnamed narrator. Their company is a welcome relief for the travel-weary prince, who learns important lessons about love, friendship, and “matters of consequence.” Toward the novel’s end, the snake promises to deliver the little prince home if he allows himself to be bitten. The prince obliges in order to be with his rose, and he soon disappears. The story concludes with the narrator looking up at the stars, wondering if the prince is somewhere among them.

One interpretation of Le Petit Prince is that life is more beautiful when the things that give it meaning are recognized and cherished, but there is a heavy irony behind this theme. The story was published during one of the lowest points in the Second World War, when France was still in the grips of its German oppressors. Saint-Exupéry himself had fled to the United States years earlier and composed Le Petit Prince during a time of personal upheaval. In short, nothing about the context of the book’s birth seemed to inspire its rosy message.   

Now, almost 80 years after the first publication of Le Petit Prince, we find ourselves in a similarly jarring and unpredictable time. As calamitous global events unfold around us, it is difficult not to feel overwhelmed. For healthcare workers, the crush of patient care has made us feel vulnerable—first to a virus that might infect us and our loved ones, and second, to the overwhelming sense of despair when caring for patients who ultimately die despite our best efforts. Pandemics are a time of physical and social disruption, and while it has been 100 years since we experienced one like this, they are a repeated part of the history of life on our planet. What would the little prince see if he landed in our clinics, hospitals, nursing homes, testing centers, or vaccination facilities today? Would he observe patients saying good-bye to family members on tablets and cell phones because their loved ones are not allowed to visit in person? Would he see healthcare workers struggling to resuscitate dying patients in a crowded emergency department or intensive care unit? Would he see long lines of cars filled with people waiting for tests or vaccines? Would he see government officials and public health workers agonizing over decisions about steps that could reduce spread but impose economic hardship on many?

There has been much debate about whether Le Petit Prince is a children’s story or a message for adults disguised as a children’s fable. Perhaps the answer is that it is both, for many children’s stories were actually written for adults. Despite the fragility and delicacy of the book, there is clearly a haunting and deep irony inherent in what it is, in effect, a most savage critique of the world at war.

Two themes that emerge in the novel resonate widely now: isolation and death. Each character the little prince meets is alone, mirroring the long periods of social distancing we have experienced over the past year. And while death is never explicitly mentioned in the book, it seems to be lurking throughout, especially when the prince disappears from Earth after being bitten by the snake. Currently, we have almost become numb to the reported daily death counts—each one alone would have evoked outrage in more usual times. One might imagine that Saint-Exupéry wrote this fable in part to help people cope with the deaths of their loved ones.

And when you are comforted (time soothes all sorrows) you will be happy to have known me. You will always be my friend. You will want to laugh with me. And from time to time you will open your window, so, just for the pleasure of it ... And your friends will be astonished to see you laughing whilst gazing at the sky! And so you will say to them, “Yes, stars always make me laugh!”

Over the past year, both authors of this essay have seen people turn to Le Petit Prince to cope with death. One of us observed a daughter reading the book to her mother at her intensive care bedside on the day she died. The other received a copy as thanks from the wife of a young man who died after 18 months of punishing chemotherapy for sarcoma. Inside the cover was a picture of her husband and the inscription, “Please share this book with someone you love—it’s meant to be read out loud—and remember James.” And so I did, with my grandson Sebastian, who listened to the story with the imagination, wonder, and curiosity of a 6-year-old—he had many questions.

Perhaps the fable that has comforted our patients and their families during their time of despair can do the same for us. Like the prince, who returns to his rose after a difficult journey, we might find solace in the people and things that give our lives their deepest meaning. Thereafter, we might return, rejuvenated, to the clinics, emergency departments, and inpatient wards where our daily work must continue. While the scale of the problems around us makes it feel like any step we take towards preserving our hope will be moot, Le Petit Prince teaches us there is value in making the effort. And there is even a chance that we will find, to our surprise, and against our more cynical judgment, a small rose pushing itself up towards the light.  

The authors thank Rita Charon (Columbia University), Pam Hartzband (Harvard University), Raphael Rush (University of Toronto), and Emily Silverman (University of California San Francisco) for their comments on earlier versions of this essay. None were compensated. We thank Sebastian, James’ wife, and our other patient’s daughter for giving permission to include them in the story.

”Good evening,“ said the little prince politely.

”Good evening,“ said the snake.

”What planet have I fallen on?“ asked the little prince.

”On the planet Earth, in Africa,“ replied the snake.

”Oh… Then there are no people on Earth?”

”This is the desert. There are no people in the desert. The Earth is big,“ said the snake.

The little prince sat down on a stone and looked up at the sky.

”I wonder,“ he said, “if the stars are lit up so that each of us can find his own star again. Look at my planet. It is right above us… But how far away is it?” ¹

Le Petit Prince is one of the twentieth century’s most widely read fables.¹ Written in 1943 by the French aviator and novelist Antoine de Saint-Exupéry, it tells the story of a young prince who inhabits a small planet in outer space with his muse, a fragile and dainty rose. The prince loves his rose and goes to great lengths to protect her, but her constant needs prove too much for him to bear. One day he decides to leave her and sets out on a journey across the universe. Along the way he stops at several different planets and interacts with their sole inhabitants, each of whom performs a bizarre and arguably pointless activity. The prince leaves each planet confused and despondent—for no place or person has proven more inspiring than his own planet or rose—until he arrives on Earth, where he meets a snake, a fox, and the novel’s unnamed narrator. Their company is a welcome relief for the travel-weary prince, who learns important lessons about love, friendship, and “matters of consequence.” Toward the novel’s end, the snake promises to deliver the little prince home if he allows himself to be bitten. The prince obliges in order to be with his rose, and he soon disappears. The story concludes with the narrator looking up at the stars, wondering if the prince is somewhere among them.

One interpretation of Le Petit Prince is that life is more beautiful when the things that give it meaning are recognized and cherished, but there is a heavy irony behind this theme. The story was published during one of the lowest points in the Second World War, when France was still in the grips of its German oppressors. Saint-Exupéry himself had fled to the United States years earlier and composed Le Petit Prince during a time of personal upheaval. In short, nothing about the context of the book’s birth seemed to inspire its rosy message.   

Now, almost 80 years after the first publication of Le Petit Prince, we find ourselves in a similarly jarring and unpredictable time. As calamitous global events unfold around us, it is difficult not to feel overwhelmed. For healthcare workers, the crush of patient care has made us feel vulnerable—first to a virus that might infect us and our loved ones, and second, to the overwhelming sense of despair when caring for patients who ultimately die despite our best efforts. Pandemics are a time of physical and social disruption, and while it has been 100 years since we experienced one like this, they are a repeated part of the history of life on our planet. What would the little prince see if he landed in our clinics, hospitals, nursing homes, testing centers, or vaccination facilities today? Would he observe patients saying good-bye to family members on tablets and cell phones because their loved ones are not allowed to visit in person? Would he see healthcare workers struggling to resuscitate dying patients in a crowded emergency department or intensive care unit? Would he see long lines of cars filled with people waiting for tests or vaccines? Would he see government officials and public health workers agonizing over decisions about steps that could reduce spread but impose economic hardship on many?

There has been much debate about whether Le Petit Prince is a children’s story or a message for adults disguised as a children’s fable. Perhaps the answer is that it is both, for many children’s stories were actually written for adults. Despite the fragility and delicacy of the book, there is clearly a haunting and deep irony inherent in what it is, in effect, a most savage critique of the world at war.

Two themes that emerge in the novel resonate widely now: isolation and death. Each character the little prince meets is alone, mirroring the long periods of social distancing we have experienced over the past year. And while death is never explicitly mentioned in the book, it seems to be lurking throughout, especially when the prince disappears from Earth after being bitten by the snake. Currently, we have almost become numb to the reported daily death counts—each one alone would have evoked outrage in more usual times. One might imagine that Saint-Exupéry wrote this fable in part to help people cope with the deaths of their loved ones.

And when you are comforted (time soothes all sorrows) you will be happy to have known me. You will always be my friend. You will want to laugh with me. And from time to time you will open your window, so, just for the pleasure of it ... And your friends will be astonished to see you laughing whilst gazing at the sky! And so you will say to them, “Yes, stars always make me laugh!”

Over the past year, both authors of this essay have seen people turn to Le Petit Prince to cope with death. One of us observed a daughter reading the book to her mother at her intensive care bedside on the day she died. The other received a copy as thanks from the wife of a young man who died after 18 months of punishing chemotherapy for sarcoma. Inside the cover was a picture of her husband and the inscription, “Please share this book with someone you love—it’s meant to be read out loud—and remember James.” And so I did, with my grandson Sebastian, who listened to the story with the imagination, wonder, and curiosity of a 6-year-old—he had many questions.

Perhaps the fable that has comforted our patients and their families during their time of despair can do the same for us. Like the prince, who returns to his rose after a difficult journey, we might find solace in the people and things that give our lives their deepest meaning. Thereafter, we might return, rejuvenated, to the clinics, emergency departments, and inpatient wards where our daily work must continue. While the scale of the problems around us makes it feel like any step we take towards preserving our hope will be moot, Le Petit Prince teaches us there is value in making the effort. And there is even a chance that we will find, to our surprise, and against our more cynical judgment, a small rose pushing itself up towards the light.  

The authors thank Rita Charon (Columbia University), Pam Hartzband (Harvard University), Raphael Rush (University of Toronto), and Emily Silverman (University of California San Francisco) for their comments on earlier versions of this essay. None were compensated. We thank Sebastian, James’ wife, and our other patient’s daughter for giving permission to include them in the story.

An intern is rotating on a medical ward in January 2018. Influenza is prevalent and hospital admissions are increasing daily. Despite receiving her influenza vaccine in October 2017, she develops fevers and myalgias. Due to time constraints, she does not get tested for influenza. She instead decides to work while sick to avoid payback of shifts.

She is now a hematology/oncology fellow in December 2020. She and her colleagues experienced the harrowing first wave of the COVID-19 pandemic. Unfortunately, community prevalence and hospital admissions are again rising. She adheres to mandatory masking and eye protection at work. Two days after attending a procedural workshop with lunch provided, she develops headache, myalgias, and sore throat. She contacts her supervisor, calls out sick, and initiates home isolation due to a positive result on a COVID-19 test performed through occupational health services (OHS). No patients are affected, but multiple colleagues are required to quarantine and others are pulled to provide coverage.

Presenteeism, the act of attending work despite personal illness, can adversely affect individuals and organizations.¹ In a healthcare setting, transmissible illnesses contribute to complications in patients and missed workdays for staff. Prior to the pandemic, the rate of presenteeism among physicians was as high as 90%.² Such presenteeism may have contributed to medical errors and decreased work efficiency.^3,4 At our hospital in the Bronx, New York, a high annual prevalence of seasonal influenza fueled influenza clusters among patients and trainees, leading to presenteeism.

Our prior work on influenza-related practices in academic medicine revealed that 54% of trainees and 26% of program directors self-reported influenza-like illness (ILI) presenteeism. Drivers included desire to display a strong work ethic, desire not to burden colleagues, concern about colleagues’ negative perceptions, and knowledge gaps in influenza transmission.⁵

The COVID-19 pandemic has profoundly affected staffing models, infection prevention protocols, use of shared spaces, educational conferences, visitation policies, and other habitual healthcare practices. The experience of post-graduate training during a pandemic has resulted in important mindset and practice changes that may decrease presenteeism. However, health systems need robust mechanisms to accommodate appropriate work absences due to illness. We hypothesize that ILI/COVID-like illness presenteeism will decrease significantly for the following reasons, which will have positive and negative impacts on the organization and individual.

Shift in Accountability and Rewards

Our 2018 study revealed that presenteeism was motivated by a desire not to burden colleagues with extra clinical duties and to display conscientiousness. Despite a back-up call system, house staff were concerned about colleagues’ negative perceptions. Accountability was perceived as fulfilling one’s assigned clinical duties rather than protecting others from illness.

More recently, staff have experienced personal or family illness with COVID-19 or witnessed its rapid spread through the healthcare system. Forty-two percent (103 of 245) of our internal medicine residents had work absences resulting in 875 total missed workdays between February 29 and May 22, 2020. At the peak of the pandemic’s first wave in the spring of 2020, 16% (38 of 245) were out sick.⁶ We hypothesize that this experience resulted in a modified sense of accountability to peers and patients which manifested as a desire not to expose them to illness. Staying home while ill is now positively reinforced by supervisors, and presenteeism is recognized as harmful rather than commendable. However, increased utilization of the back-up call system to meet patient care demands is a secondary consequence.

Consequences of Exposures

While trainees and program faculty acknowledged that presenteeism puts patients and coworkers at risk,⁵ there was insufficient individual or institutional motivation to prevent it or fear its consequences pre-pandemic. An individual infected with influenza A may spread illness to one or two others, and several outpatient influenza treatments exist. Also, current trainees did not experience the prior respiratory viral pandemic (2009 H1N1 influenza A) as healthcare workers (HCWs).

In contrast, SARS-CoV-2 is more transmissible, with one infection resulting in two to three additional cases.⁷ Hence, mandatory quarantine and isolation policies are more stringent than those for influenza. While reinfection with SARS-CoV-2 is rare,⁸ HCWs can be exposed and quarantined multiple times, which potentially impacts paid sick leave for HCWs and elective-time for house staff pursuing fellowships. COVID-19 among HCWs also impacts secondary contacts, resulting in missed work and school days and strain on families. Hospital resource utilization for contact tracing and testing postexposure is significant. Unlike influenza, there are currently no oral antiviral treatments for outpatient COVID-19, and illness has been linked to chronic disabling symptoms.⁹ Finally, absences due to illness or quarantine may disrupt education, training, and fulfillment of competencies and experiences necessary for advancement.

We predict that these potentially sweeping consequences will reduce presenteeism. An important aspect of health system pandemic planning must include adequate staffing to account for work absences due to illness or quarantine.

Access to Occupational Health Services

Previously, staff reported barriers to seeking care from OHS. Therefore, this step was skipped, and HCWs managed their own symptoms, tested and treated each other for influenza, and returned to work at an arbitrary interval, without coordination with OHS protocols. OHS processes have since greatly improved. Employees with a COVID-19 exposure or concerning symptoms call the OHS hotline, are referred for same-day testing, and are given specific instructions regarding home quarantine or isolation and return to work. Follow-up to confirm fitness for duty is provided. In September 2020, an electronic screening tool assessing COVID-19 symptoms, exposures, and high-risk travel was implemented at our institution. Associates must present their clearance at hospital entrances.

Protection From Vaccine

Survey results indicated that all house staff and program faculty received the annual influenza vaccine.⁵ In New York State, public health regulations ensure a high rate of annual influenza vaccination among HCWs.¹⁰ It is possible that house staff did not perceive that ILI symptoms were caused by influenza after vaccination, and that vaccinated colleagues were at lower risk of illness. The influenza vaccine also has a well-established safety record, contributing to good uptake among HCWs.

At the time of writing of this article, HCWs have been prioritized for COVID-19 vaccination. Studies are in progress pertaining to the degree of protection after one dose, incidence of new infections after first and second doses, and secondary transmissions from vaccinated individuals. Vaccination is likely to influence HCW behaviors as well as occupational health policies. We suggest that the impact of COVID-19 vaccination on subsequent HCW presenteeism be given precedence in future studies.

Consistent Messaging and Communication

Prior to the pandemic, regular communication to staff on transmissible disease outbreaks scarcely occurred. Likewise, recurring training on infection prevention and personal protective equipment (PPE) protocols did not occur, and hospital policies regarding personal illness were not emphasized. Harms of presenteeism were infrequently addressed outside of nosocomial outbreaks. The pandemic has positively impacted communication from hospital leadership. Infection control and occupational health guidelines are continually revised and disseminated. Program directors send regular COVID-19 updates to trainees. The infectious diseases program director serves as a graduate medical education liaison to hospital leadership. All staff are regularly updated on evolving policies and given resources to assist with personal illness. While many positive practice changes have occurred, a decrease in presenteeism may exhaust sick coverage and compromise patient care. We suggest that health systems create safer work environments and ensure adequate staffing to accommodate illnesses and quarantines.

• Conduct recurring staff PPE simulations spanning a range of communicable illnesses.
• Ensure adequate PPE for surge conditions.
• Implement occupancy limits for shared spaces, distanced seating, staggered mealtimes, plexiglass barriers, and portable air-filtration systems in rooms lacking windows.
• Invest in large-scale, serial testing of asymptomatic HCWs to identify early cases and enact quarantines prior to excess exposures.

• Adopt nonpunitive coverage systems, reducing presenteeism by removing expectations to “pay-back” colleagues later.
• Establish a third-party notification system, reducing strain on house staff to find coverage. This will enable strategic use of the jeopardy pool by training program leadership.
• Establish a backup coverage pool populated by hospitalists and third-year residents who have completed fellowship match. Ideally, health systems should be prepared to compensate physicians for extra shifts.
• Engage nondeployed physician assistants or nurse practitioners to provide coverage for residents on a per diem basis.
• At a federal level, funding for trainee workforce expansion can occur to ensure staffing redundancy. The appropriate number of trainees should be determined by program leadership, balancing surge needs with education and autonomy. Likewise, training extensions due to COVID-related absences or deployments away from research or electives should be federally funded.
• Inpatient and community COVID-19 surges can result in large-scale furloughs of HCWs; hospital leadership should expediently implement public health recommendations allowing fully immunized HCWs to work after exposures while maximally adhering to infection prevention protocols.

The COVID-19 pandemic has profoundly impacted academic medicine. It is imperative to explore solutions to balance workplace safety, education, and training with staffing constraints and patient care needs. Resource investment and executive leadership support are required to achieve this balance.

An intern is rotating on a medical ward in January 2018. Influenza is prevalent and hospital admissions are increasing daily. Despite receiving her influenza vaccine in October 2017, she develops fevers and myalgias. Due to time constraints, she does not get tested for influenza. She instead decides to work while sick to avoid payback of shifts.

She is now a hematology/oncology fellow in December 2020. She and her colleagues experienced the harrowing first wave of the COVID-19 pandemic. Unfortunately, community prevalence and hospital admissions are again rising. She adheres to mandatory masking and eye protection at work. Two days after attending a procedural workshop with lunch provided, she develops headache, myalgias, and sore throat. She contacts her supervisor, calls out sick, and initiates home isolation due to a positive result on a COVID-19 test performed through occupational health services (OHS). No patients are affected, but multiple colleagues are required to quarantine and others are pulled to provide coverage.

Presenteeism, the act of attending work despite personal illness, can adversely affect individuals and organizations.¹ In a healthcare setting, transmissible illnesses contribute to complications in patients and missed workdays for staff. Prior to the pandemic, the rate of presenteeism among physicians was as high as 90%.² Such presenteeism may have contributed to medical errors and decreased work efficiency.^3,4 At our hospital in the Bronx, New York, a high annual prevalence of seasonal influenza fueled influenza clusters among patients and trainees, leading to presenteeism.

Our prior work on influenza-related practices in academic medicine revealed that 54% of trainees and 26% of program directors self-reported influenza-like illness (ILI) presenteeism. Drivers included desire to display a strong work ethic, desire not to burden colleagues, concern about colleagues’ negative perceptions, and knowledge gaps in influenza transmission.⁵

The COVID-19 pandemic has profoundly affected staffing models, infection prevention protocols, use of shared spaces, educational conferences, visitation policies, and other habitual healthcare practices. The experience of post-graduate training during a pandemic has resulted in important mindset and practice changes that may decrease presenteeism. However, health systems need robust mechanisms to accommodate appropriate work absences due to illness. We hypothesize that ILI/COVID-like illness presenteeism will decrease significantly for the following reasons, which will have positive and negative impacts on the organization and individual.

Shift in Accountability and Rewards

Our 2018 study revealed that presenteeism was motivated by a desire not to burden colleagues with extra clinical duties and to display conscientiousness. Despite a back-up call system, house staff were concerned about colleagues’ negative perceptions. Accountability was perceived as fulfilling one’s assigned clinical duties rather than protecting others from illness.

More recently, staff have experienced personal or family illness with COVID-19 or witnessed its rapid spread through the healthcare system. Forty-two percent (103 of 245) of our internal medicine residents had work absences resulting in 875 total missed workdays between February 29 and May 22, 2020. At the peak of the pandemic’s first wave in the spring of 2020, 16% (38 of 245) were out sick.⁶ We hypothesize that this experience resulted in a modified sense of accountability to peers and patients which manifested as a desire not to expose them to illness. Staying home while ill is now positively reinforced by supervisors, and presenteeism is recognized as harmful rather than commendable. However, increased utilization of the back-up call system to meet patient care demands is a secondary consequence.

Consequences of Exposures

While trainees and program faculty acknowledged that presenteeism puts patients and coworkers at risk,⁵ there was insufficient individual or institutional motivation to prevent it or fear its consequences pre-pandemic. An individual infected with influenza A may spread illness to one or two others, and several outpatient influenza treatments exist. Also, current trainees did not experience the prior respiratory viral pandemic (2009 H1N1 influenza A) as healthcare workers (HCWs).

In contrast, SARS-CoV-2 is more transmissible, with one infection resulting in two to three additional cases.⁷ Hence, mandatory quarantine and isolation policies are more stringent than those for influenza. While reinfection with SARS-CoV-2 is rare,⁸ HCWs can be exposed and quarantined multiple times, which potentially impacts paid sick leave for HCWs and elective-time for house staff pursuing fellowships. COVID-19 among HCWs also impacts secondary contacts, resulting in missed work and school days and strain on families. Hospital resource utilization for contact tracing and testing postexposure is significant. Unlike influenza, there are currently no oral antiviral treatments for outpatient COVID-19, and illness has been linked to chronic disabling symptoms.⁹ Finally, absences due to illness or quarantine may disrupt education, training, and fulfillment of competencies and experiences necessary for advancement.

We predict that these potentially sweeping consequences will reduce presenteeism. An important aspect of health system pandemic planning must include adequate staffing to account for work absences due to illness or quarantine.

Access to Occupational Health Services

Previously, staff reported barriers to seeking care from OHS. Therefore, this step was skipped, and HCWs managed their own symptoms, tested and treated each other for influenza, and returned to work at an arbitrary interval, without coordination with OHS protocols. OHS processes have since greatly improved. Employees with a COVID-19 exposure or concerning symptoms call the OHS hotline, are referred for same-day testing, and are given specific instructions regarding home quarantine or isolation and return to work. Follow-up to confirm fitness for duty is provided. In September 2020, an electronic screening tool assessing COVID-19 symptoms, exposures, and high-risk travel was implemented at our institution. Associates must present their clearance at hospital entrances.

Protection From Vaccine

Survey results indicated that all house staff and program faculty received the annual influenza vaccine.⁵ In New York State, public health regulations ensure a high rate of annual influenza vaccination among HCWs.¹⁰ It is possible that house staff did not perceive that ILI symptoms were caused by influenza after vaccination, and that vaccinated colleagues were at lower risk of illness. The influenza vaccine also has a well-established safety record, contributing to good uptake among HCWs.

At the time of writing of this article, HCWs have been prioritized for COVID-19 vaccination. Studies are in progress pertaining to the degree of protection after one dose, incidence of new infections after first and second doses, and secondary transmissions from vaccinated individuals. Vaccination is likely to influence HCW behaviors as well as occupational health policies. We suggest that the impact of COVID-19 vaccination on subsequent HCW presenteeism be given precedence in future studies.

Consistent Messaging and Communication

Prior to the pandemic, regular communication to staff on transmissible disease outbreaks scarcely occurred. Likewise, recurring training on infection prevention and personal protective equipment (PPE) protocols did not occur, and hospital policies regarding personal illness were not emphasized. Harms of presenteeism were infrequently addressed outside of nosocomial outbreaks. The pandemic has positively impacted communication from hospital leadership. Infection control and occupational health guidelines are continually revised and disseminated. Program directors send regular COVID-19 updates to trainees. The infectious diseases program director serves as a graduate medical education liaison to hospital leadership. All staff are regularly updated on evolving policies and given resources to assist with personal illness. While many positive practice changes have occurred, a decrease in presenteeism may exhaust sick coverage and compromise patient care. We suggest that health systems create safer work environments and ensure adequate staffing to accommodate illnesses and quarantines.

• Conduct recurring staff PPE simulations spanning a range of communicable illnesses.
• Ensure adequate PPE for surge conditions.
• Implement occupancy limits for shared spaces, distanced seating, staggered mealtimes, plexiglass barriers, and portable air-filtration systems in rooms lacking windows.
• Invest in large-scale, serial testing of asymptomatic HCWs to identify early cases and enact quarantines prior to excess exposures.

• Adopt nonpunitive coverage systems, reducing presenteeism by removing expectations to “pay-back” colleagues later.
• Establish a third-party notification system, reducing strain on house staff to find coverage. This will enable strategic use of the jeopardy pool by training program leadership.
• Establish a backup coverage pool populated by hospitalists and third-year residents who have completed fellowship match. Ideally, health systems should be prepared to compensate physicians for extra shifts.
• Engage nondeployed physician assistants or nurse practitioners to provide coverage for residents on a per diem basis.
• At a federal level, funding for trainee workforce expansion can occur to ensure staffing redundancy. The appropriate number of trainees should be determined by program leadership, balancing surge needs with education and autonomy. Likewise, training extensions due to COVID-related absences or deployments away from research or electives should be federally funded.
• Inpatient and community COVID-19 surges can result in large-scale furloughs of HCWs; hospital leadership should expediently implement public health recommendations allowing fully immunized HCWs to work after exposures while maximally adhering to infection prevention protocols.

The COVID-19 pandemic has profoundly impacted academic medicine. It is imperative to explore solutions to balance workplace safety, education, and training with staffing constraints and patient care needs. Resource investment and executive leadership support are required to achieve this balance.

An intern is rotating on a medical ward in January 2018. Influenza is prevalent and hospital admissions are increasing daily. Despite receiving her influenza vaccine in October 2017, she develops fevers and myalgias. Due to time constraints, she does not get tested for influenza. She instead decides to work while sick to avoid payback of shifts.

She is now a hematology/oncology fellow in December 2020. She and her colleagues experienced the harrowing first wave of the COVID-19 pandemic. Unfortunately, community prevalence and hospital admissions are again rising. She adheres to mandatory masking and eye protection at work. Two days after attending a procedural workshop with lunch provided, she develops headache, myalgias, and sore throat. She contacts her supervisor, calls out sick, and initiates home isolation due to a positive result on a COVID-19 test performed through occupational health services (OHS). No patients are affected, but multiple colleagues are required to quarantine and others are pulled to provide coverage.

Presenteeism, the act of attending work despite personal illness, can adversely affect individuals and organizations.¹ In a healthcare setting, transmissible illnesses contribute to complications in patients and missed workdays for staff. Prior to the pandemic, the rate of presenteeism among physicians was as high as 90%.² Such presenteeism may have contributed to medical errors and decreased work efficiency.^3,4 At our hospital in the Bronx, New York, a high annual prevalence of seasonal influenza fueled influenza clusters among patients and trainees, leading to presenteeism.

Our prior work on influenza-related practices in academic medicine revealed that 54% of trainees and 26% of program directors self-reported influenza-like illness (ILI) presenteeism. Drivers included desire to display a strong work ethic, desire not to burden colleagues, concern about colleagues’ negative perceptions, and knowledge gaps in influenza transmission.⁵

The COVID-19 pandemic has profoundly affected staffing models, infection prevention protocols, use of shared spaces, educational conferences, visitation policies, and other habitual healthcare practices. The experience of post-graduate training during a pandemic has resulted in important mindset and practice changes that may decrease presenteeism. However, health systems need robust mechanisms to accommodate appropriate work absences due to illness. We hypothesize that ILI/COVID-like illness presenteeism will decrease significantly for the following reasons, which will have positive and negative impacts on the organization and individual.

Shift in Accountability and Rewards

Our 2018 study revealed that presenteeism was motivated by a desire not to burden colleagues with extra clinical duties and to display conscientiousness. Despite a back-up call system, house staff were concerned about colleagues’ negative perceptions. Accountability was perceived as fulfilling one’s assigned clinical duties rather than protecting others from illness.

More recently, staff have experienced personal or family illness with COVID-19 or witnessed its rapid spread through the healthcare system. Forty-two percent (103 of 245) of our internal medicine residents had work absences resulting in 875 total missed workdays between February 29 and May 22, 2020. At the peak of the pandemic’s first wave in the spring of 2020, 16% (38 of 245) were out sick.⁶ We hypothesize that this experience resulted in a modified sense of accountability to peers and patients which manifested as a desire not to expose them to illness. Staying home while ill is now positively reinforced by supervisors, and presenteeism is recognized as harmful rather than commendable. However, increased utilization of the back-up call system to meet patient care demands is a secondary consequence.

Consequences of Exposures

While trainees and program faculty acknowledged that presenteeism puts patients and coworkers at risk,⁵ there was insufficient individual or institutional motivation to prevent it or fear its consequences pre-pandemic. An individual infected with influenza A may spread illness to one or two others, and several outpatient influenza treatments exist. Also, current trainees did not experience the prior respiratory viral pandemic (2009 H1N1 influenza A) as healthcare workers (HCWs).

In contrast, SARS-CoV-2 is more transmissible, with one infection resulting in two to three additional cases.⁷ Hence, mandatory quarantine and isolation policies are more stringent than those for influenza. While reinfection with SARS-CoV-2 is rare,⁸ HCWs can be exposed and quarantined multiple times, which potentially impacts paid sick leave for HCWs and elective-time for house staff pursuing fellowships. COVID-19 among HCWs also impacts secondary contacts, resulting in missed work and school days and strain on families. Hospital resource utilization for contact tracing and testing postexposure is significant. Unlike influenza, there are currently no oral antiviral treatments for outpatient COVID-19, and illness has been linked to chronic disabling symptoms.⁹ Finally, absences due to illness or quarantine may disrupt education, training, and fulfillment of competencies and experiences necessary for advancement.

We predict that these potentially sweeping consequences will reduce presenteeism. An important aspect of health system pandemic planning must include adequate staffing to account for work absences due to illness or quarantine.

Access to Occupational Health Services

Previously, staff reported barriers to seeking care from OHS. Therefore, this step was skipped, and HCWs managed their own symptoms, tested and treated each other for influenza, and returned to work at an arbitrary interval, without coordination with OHS protocols. OHS processes have since greatly improved. Employees with a COVID-19 exposure or concerning symptoms call the OHS hotline, are referred for same-day testing, and are given specific instructions regarding home quarantine or isolation and return to work. Follow-up to confirm fitness for duty is provided. In September 2020, an electronic screening tool assessing COVID-19 symptoms, exposures, and high-risk travel was implemented at our institution. Associates must present their clearance at hospital entrances.

Protection From Vaccine

Survey results indicated that all house staff and program faculty received the annual influenza vaccine.⁵ In New York State, public health regulations ensure a high rate of annual influenza vaccination among HCWs.¹⁰ It is possible that house staff did not perceive that ILI symptoms were caused by influenza after vaccination, and that vaccinated colleagues were at lower risk of illness. The influenza vaccine also has a well-established safety record, contributing to good uptake among HCWs.

At the time of writing of this article, HCWs have been prioritized for COVID-19 vaccination. Studies are in progress pertaining to the degree of protection after one dose, incidence of new infections after first and second doses, and secondary transmissions from vaccinated individuals. Vaccination is likely to influence HCW behaviors as well as occupational health policies. We suggest that the impact of COVID-19 vaccination on subsequent HCW presenteeism be given precedence in future studies.

Consistent Messaging and Communication

Prior to the pandemic, regular communication to staff on transmissible disease outbreaks scarcely occurred. Likewise, recurring training on infection prevention and personal protective equipment (PPE) protocols did not occur, and hospital policies regarding personal illness were not emphasized. Harms of presenteeism were infrequently addressed outside of nosocomial outbreaks. The pandemic has positively impacted communication from hospital leadership. Infection control and occupational health guidelines are continually revised and disseminated. Program directors send regular COVID-19 updates to trainees. The infectious diseases program director serves as a graduate medical education liaison to hospital leadership. All staff are regularly updated on evolving policies and given resources to assist with personal illness. While many positive practice changes have occurred, a decrease in presenteeism may exhaust sick coverage and compromise patient care. We suggest that health systems create safer work environments and ensure adequate staffing to accommodate illnesses and quarantines.

• Conduct recurring staff PPE simulations spanning a range of communicable illnesses.
• Ensure adequate PPE for surge conditions.
• Implement occupancy limits for shared spaces, distanced seating, staggered mealtimes, plexiglass barriers, and portable air-filtration systems in rooms lacking windows.
• Invest in large-scale, serial testing of asymptomatic HCWs to identify early cases and enact quarantines prior to excess exposures.

• Adopt nonpunitive coverage systems, reducing presenteeism by removing expectations to “pay-back” colleagues later.
• Establish a third-party notification system, reducing strain on house staff to find coverage. This will enable strategic use of the jeopardy pool by training program leadership.
• Establish a backup coverage pool populated by hospitalists and third-year residents who have completed fellowship match. Ideally, health systems should be prepared to compensate physicians for extra shifts.
• Engage nondeployed physician assistants or nurse practitioners to provide coverage for residents on a per diem basis.
• At a federal level, funding for trainee workforce expansion can occur to ensure staffing redundancy. The appropriate number of trainees should be determined by program leadership, balancing surge needs with education and autonomy. Likewise, training extensions due to COVID-related absences or deployments away from research or electives should be federally funded.
• Inpatient and community COVID-19 surges can result in large-scale furloughs of HCWs; hospital leadership should expediently implement public health recommendations allowing fully immunized HCWs to work after exposures while maximally adhering to infection prevention protocols.

The COVID-19 pandemic has profoundly impacted academic medicine. It is imperative to explore solutions to balance workplace safety, education, and training with staffing constraints and patient care needs. Resource investment and executive leadership support are required to achieve this balance.

A celebratory mood pervaded the last week of service for my ward team at the end of the academic year. As the attending, it was just another day, but it was hard not to be caught up in the general feeling of a milestone flying past. Like most days in a hospital, this one passed in a rhythm of alternating mundanity and crisis. Late in the afternoon, one of the residents called me to a bedside for help. Imagining that my diagnostic skills were urgently required, I took the stairs. The problem, as it turned out, was not strictly medical.

I could hear the yelling before I cleared the locked entry doors to the ward. It doesn’t really matter what the yelling was about, just that there is often yelling and there is always very little I can do about the root cause of it. As I stepped into the middle of the conflagration, I remembered the story an intern told me about the night earlier in the month when it fell to her to wheel the same patient’s intoxicated parent down to the emergency department. After sleeping it off, the parent was diagnosed with an “allergic reaction” and given a prescription for diphenhydramine. We all knew the diagnosis was fantasy, and yet we all went along with it because there was simply no help available for the root cause of the problem. State social services was already involved, and we had a “safety” plan in place for discharge. As meager as that may have been, we had done the best we could to balance the risk with the available resources… or so we told ourselves.

As a nation, we have chosen not to provide much of a social safety net for our citizens who suffer from addiction and/or mental illness and, most importantly, for those who’ve just not had a leg up on the economic ladder. As a hospital-based clinician, I know that people in distress lose their cool and yell sometimes. Ironically, they may yell most loudly at people who sincerely want to help, simply because others do not engage them. Medical schools don’t teach us how to handle the yelling, though many would say it is part of the hidden curriculum. One thing that distinguishes many pediatricians like myself is a willingness to listen to the yelling, to engage with it, and to try to help. Not surprisingly, our reputation around the hospital is that we skew a bit naive.

It is worth asking, though: Are pediatricians naive? Sure, we make funny faces. We clown. We baby-talk. Those things are largely true, but there are other true things about pediatricians. Chief among them is the fact that we come to know some of the worst things there are to know about human beings. Everybody knows people can be awful, but we know exactly how awful they are to defenseless children in precise detail. For instance, I’ve seen a 4-year-old who was repeatedly starved as a regular punishment. She was so hungry she ate her hair, which turned out to be lucky for her because it caused an intestinal blockage that led to the discovery of the abuse. I gave her an apple one day and she immediately hid it under her shirt. Where you see a scab on a child’s inner arm, I see a cigarette burn. I’ve resuscitated a baby whose parents dipped his pacifier in heroin to stop his crying—the remarkable part of the story being that it was heroin cooked in the hospital bathroom. And then there are the things that I cannot even bring myself to write down.

Carrying this knowledge hollows out a gap between pediatricians and the rest of the world. The divergence between our expectations of how a society should treat its children and the reality of our daily experience grinds away any naivete. The gap becomes a canyon for some of us. We live with the sense that nobody would believe the things we’ve seen, so we rarely talk about them. Years ago, I was testifying in a (for me) routine child-abuse case where this fact hit home. It is common for juries to disbelieve that a caregiver could do the things we allege. I say allege, but if you work as a pediatrician long enough, the space between allegation and fact narrows. It is simply pattern recognition to you—abuse happens so consistently that we accept it as a diagnostic category. The case in question was a submersion burn, which is an almost unmistakable pattern. The other piece of the story is that it happens to toddlers during toilet training as caregivers lose their self-control and punish children for soiling themselves. For me, simple pattern recognition; for the jury, simply unbelievable. We lost the case.

We are almost always losing the case as pediatricians. Spending on children makes up less than 10% of the federal budget, whereas spending on the elderly, including Social Security, Medicare, and the adult component of Medicaid, dominates that budget.¹ Moreover, twice as many children as adults over age 65 are living in poverty in the United States. The Temporary Assistance for Needy Families program is often debated in this country and frequently criticized as wasteful. However, what is not debatable is that the allocated budget ($16.5 billion) hasn’t changed since 1996, resulting in a functional 40% decrease due to inflation.² Life, for poor children, gets a little tougher every year.

After the resident and I wrapped up our day, we talked a little about how hard it is to witness some of the things you see in a children’s hospital. I could see the gap between her and the outside world widening right in front of me. In my weaker moments, I want to tell trainees like her to run while they can. I want to warn them that they don’t want to know so many of the things we’re going to teach them. I know how the story usually ends. I know that our country doesn’t promise children safety from social deprivation, hunger, or physical abuse. Instead, we’ve created the conditions for those things to occur at embarrassingly high rates, and we prosecute the unlucky after the fact. The children are simply collateral damage.

We stood at our patient’s bedside and tried to imagine a happy future. Even without his medical problems, he would likely need a major investment of resources in order to thrive. Where would those resources come from? I saw the hospital crib, metal bars on all sides and a thick plastic roof to prevent escape, as a metaphor. Later, I took the elevator down and overheard a snippet of conversation between two residents. One of them asked the other, “How do you know when you’ve burned out?” The other replied, “I don’t know, I guess when you’ve stopped burning.” Burnout is a hot topic in medicine, and some may assume the reasons are obvious: long hours and intellectually demanding work. In reality, those drivers may be less important than the repeated exposure to profound injustice inherent to the practice of medicine in our country.

As hospitalists, we address acute decompensation in our patients and send them back out into the world knowing there will soon be a next time. We also know that the next time might be preventable, if only … This cycle sometimes feels inexorable, but it can also prompt us to think about our obligation to work toward a more just society. We have to imagine a better future even as we struggle to believe it is on the way.

Most of our hospitals are trying to help. They have community-engagement programs, they purchase housing for homeless patients, they provide large amounts of uncompensated care and sometimes operate at a loss. Yet none of this addresses the root cause of the problem. Medicine, either in the form of an institution or a doctor, can’t replace a just society, but the truth of this fact does not mean we should not try.

Pediatrics has always been a field disposed toward advocacy. The origin of our largest professional organization in the United States was the intraprofessional conflict within the American Medical Association (AMA) over the Sheppard-Towner Act of 1921, one of this country’s first attempts to address the social determinants of health with legislation.³ The American Academy of Pediatrics was formed in 1930 after the AMA House of Delegates rebuked the Pediatric section for advocating for continuance of the act during the late 1920s.³ Perhaps what Pediatrics has to teach the rest of medicine is the necessity of making advocacy a part of our professional identity. And perhaps that’s the reason that so many pediatricians are still burning and not burned out.

A celebratory mood pervaded the last week of service for my ward team at the end of the academic year. As the attending, it was just another day, but it was hard not to be caught up in the general feeling of a milestone flying past. Like most days in a hospital, this one passed in a rhythm of alternating mundanity and crisis. Late in the afternoon, one of the residents called me to a bedside for help. Imagining that my diagnostic skills were urgently required, I took the stairs. The problem, as it turned out, was not strictly medical.

I could hear the yelling before I cleared the locked entry doors to the ward. It doesn’t really matter what the yelling was about, just that there is often yelling and there is always very little I can do about the root cause of it. As I stepped into the middle of the conflagration, I remembered the story an intern told me about the night earlier in the month when it fell to her to wheel the same patient’s intoxicated parent down to the emergency department. After sleeping it off, the parent was diagnosed with an “allergic reaction” and given a prescription for diphenhydramine. We all knew the diagnosis was fantasy, and yet we all went along with it because there was simply no help available for the root cause of the problem. State social services was already involved, and we had a “safety” plan in place for discharge. As meager as that may have been, we had done the best we could to balance the risk with the available resources… or so we told ourselves.

As a nation, we have chosen not to provide much of a social safety net for our citizens who suffer from addiction and/or mental illness and, most importantly, for those who’ve just not had a leg up on the economic ladder. As a hospital-based clinician, I know that people in distress lose their cool and yell sometimes. Ironically, they may yell most loudly at people who sincerely want to help, simply because others do not engage them. Medical schools don’t teach us how to handle the yelling, though many would say it is part of the hidden curriculum. One thing that distinguishes many pediatricians like myself is a willingness to listen to the yelling, to engage with it, and to try to help. Not surprisingly, our reputation around the hospital is that we skew a bit naive.

It is worth asking, though: Are pediatricians naive? Sure, we make funny faces. We clown. We baby-talk. Those things are largely true, but there are other true things about pediatricians. Chief among them is the fact that we come to know some of the worst things there are to know about human beings. Everybody knows people can be awful, but we know exactly how awful they are to defenseless children in precise detail. For instance, I’ve seen a 4-year-old who was repeatedly starved as a regular punishment. She was so hungry she ate her hair, which turned out to be lucky for her because it caused an intestinal blockage that led to the discovery of the abuse. I gave her an apple one day and she immediately hid it under her shirt. Where you see a scab on a child’s inner arm, I see a cigarette burn. I’ve resuscitated a baby whose parents dipped his pacifier in heroin to stop his crying—the remarkable part of the story being that it was heroin cooked in the hospital bathroom. And then there are the things that I cannot even bring myself to write down.

Carrying this knowledge hollows out a gap between pediatricians and the rest of the world. The divergence between our expectations of how a society should treat its children and the reality of our daily experience grinds away any naivete. The gap becomes a canyon for some of us. We live with the sense that nobody would believe the things we’ve seen, so we rarely talk about them. Years ago, I was testifying in a (for me) routine child-abuse case where this fact hit home. It is common for juries to disbelieve that a caregiver could do the things we allege. I say allege, but if you work as a pediatrician long enough, the space between allegation and fact narrows. It is simply pattern recognition to you—abuse happens so consistently that we accept it as a diagnostic category. The case in question was a submersion burn, which is an almost unmistakable pattern. The other piece of the story is that it happens to toddlers during toilet training as caregivers lose their self-control and punish children for soiling themselves. For me, simple pattern recognition; for the jury, simply unbelievable. We lost the case.

We are almost always losing the case as pediatricians. Spending on children makes up less than 10% of the federal budget, whereas spending on the elderly, including Social Security, Medicare, and the adult component of Medicaid, dominates that budget.¹ Moreover, twice as many children as adults over age 65 are living in poverty in the United States. The Temporary Assistance for Needy Families program is often debated in this country and frequently criticized as wasteful. However, what is not debatable is that the allocated budget ($16.5 billion) hasn’t changed since 1996, resulting in a functional 40% decrease due to inflation.² Life, for poor children, gets a little tougher every year.

After the resident and I wrapped up our day, we talked a little about how hard it is to witness some of the things you see in a children’s hospital. I could see the gap between her and the outside world widening right in front of me. In my weaker moments, I want to tell trainees like her to run while they can. I want to warn them that they don’t want to know so many of the things we’re going to teach them. I know how the story usually ends. I know that our country doesn’t promise children safety from social deprivation, hunger, or physical abuse. Instead, we’ve created the conditions for those things to occur at embarrassingly high rates, and we prosecute the unlucky after the fact. The children are simply collateral damage.

We stood at our patient’s bedside and tried to imagine a happy future. Even without his medical problems, he would likely need a major investment of resources in order to thrive. Where would those resources come from? I saw the hospital crib, metal bars on all sides and a thick plastic roof to prevent escape, as a metaphor. Later, I took the elevator down and overheard a snippet of conversation between two residents. One of them asked the other, “How do you know when you’ve burned out?” The other replied, “I don’t know, I guess when you’ve stopped burning.” Burnout is a hot topic in medicine, and some may assume the reasons are obvious: long hours and intellectually demanding work. In reality, those drivers may be less important than the repeated exposure to profound injustice inherent to the practice of medicine in our country.

As hospitalists, we address acute decompensation in our patients and send them back out into the world knowing there will soon be a next time. We also know that the next time might be preventable, if only … This cycle sometimes feels inexorable, but it can also prompt us to think about our obligation to work toward a more just society. We have to imagine a better future even as we struggle to believe it is on the way.

Most of our hospitals are trying to help. They have community-engagement programs, they purchase housing for homeless patients, they provide large amounts of uncompensated care and sometimes operate at a loss. Yet none of this addresses the root cause of the problem. Medicine, either in the form of an institution or a doctor, can’t replace a just society, but the truth of this fact does not mean we should not try.

Pediatrics has always been a field disposed toward advocacy. The origin of our largest professional organization in the United States was the intraprofessional conflict within the American Medical Association (AMA) over the Sheppard-Towner Act of 1921, one of this country’s first attempts to address the social determinants of health with legislation.³ The American Academy of Pediatrics was formed in 1930 after the AMA House of Delegates rebuked the Pediatric section for advocating for continuance of the act during the late 1920s.³ Perhaps what Pediatrics has to teach the rest of medicine is the necessity of making advocacy a part of our professional identity. And perhaps that’s the reason that so many pediatricians are still burning and not burned out.

A celebratory mood pervaded the last week of service for my ward team at the end of the academic year. As the attending, it was just another day, but it was hard not to be caught up in the general feeling of a milestone flying past. Like most days in a hospital, this one passed in a rhythm of alternating mundanity and crisis. Late in the afternoon, one of the residents called me to a bedside for help. Imagining that my diagnostic skills were urgently required, I took the stairs. The problem, as it turned out, was not strictly medical.

I could hear the yelling before I cleared the locked entry doors to the ward. It doesn’t really matter what the yelling was about, just that there is often yelling and there is always very little I can do about the root cause of it. As I stepped into the middle of the conflagration, I remembered the story an intern told me about the night earlier in the month when it fell to her to wheel the same patient’s intoxicated parent down to the emergency department. After sleeping it off, the parent was diagnosed with an “allergic reaction” and given a prescription for diphenhydramine. We all knew the diagnosis was fantasy, and yet we all went along with it because there was simply no help available for the root cause of the problem. State social services was already involved, and we had a “safety” plan in place for discharge. As meager as that may have been, we had done the best we could to balance the risk with the available resources… or so we told ourselves.

As a nation, we have chosen not to provide much of a social safety net for our citizens who suffer from addiction and/or mental illness and, most importantly, for those who’ve just not had a leg up on the economic ladder. As a hospital-based clinician, I know that people in distress lose their cool and yell sometimes. Ironically, they may yell most loudly at people who sincerely want to help, simply because others do not engage them. Medical schools don’t teach us how to handle the yelling, though many would say it is part of the hidden curriculum. One thing that distinguishes many pediatricians like myself is a willingness to listen to the yelling, to engage with it, and to try to help. Not surprisingly, our reputation around the hospital is that we skew a bit naive.

It is worth asking, though: Are pediatricians naive? Sure, we make funny faces. We clown. We baby-talk. Those things are largely true, but there are other true things about pediatricians. Chief among them is the fact that we come to know some of the worst things there are to know about human beings. Everybody knows people can be awful, but we know exactly how awful they are to defenseless children in precise detail. For instance, I’ve seen a 4-year-old who was repeatedly starved as a regular punishment. She was so hungry she ate her hair, which turned out to be lucky for her because it caused an intestinal blockage that led to the discovery of the abuse. I gave her an apple one day and she immediately hid it under her shirt. Where you see a scab on a child’s inner arm, I see a cigarette burn. I’ve resuscitated a baby whose parents dipped his pacifier in heroin to stop his crying—the remarkable part of the story being that it was heroin cooked in the hospital bathroom. And then there are the things that I cannot even bring myself to write down.

Carrying this knowledge hollows out a gap between pediatricians and the rest of the world. The divergence between our expectations of how a society should treat its children and the reality of our daily experience grinds away any naivete. The gap becomes a canyon for some of us. We live with the sense that nobody would believe the things we’ve seen, so we rarely talk about them. Years ago, I was testifying in a (for me) routine child-abuse case where this fact hit home. It is common for juries to disbelieve that a caregiver could do the things we allege. I say allege, but if you work as a pediatrician long enough, the space between allegation and fact narrows. It is simply pattern recognition to you—abuse happens so consistently that we accept it as a diagnostic category. The case in question was a submersion burn, which is an almost unmistakable pattern. The other piece of the story is that it happens to toddlers during toilet training as caregivers lose their self-control and punish children for soiling themselves. For me, simple pattern recognition; for the jury, simply unbelievable. We lost the case.

We are almost always losing the case as pediatricians. Spending on children makes up less than 10% of the federal budget, whereas spending on the elderly, including Social Security, Medicare, and the adult component of Medicaid, dominates that budget.¹ Moreover, twice as many children as adults over age 65 are living in poverty in the United States. The Temporary Assistance for Needy Families program is often debated in this country and frequently criticized as wasteful. However, what is not debatable is that the allocated budget ($16.5 billion) hasn’t changed since 1996, resulting in a functional 40% decrease due to inflation.² Life, for poor children, gets a little tougher every year.

After the resident and I wrapped up our day, we talked a little about how hard it is to witness some of the things you see in a children’s hospital. I could see the gap between her and the outside world widening right in front of me. In my weaker moments, I want to tell trainees like her to run while they can. I want to warn them that they don’t want to know so many of the things we’re going to teach them. I know how the story usually ends. I know that our country doesn’t promise children safety from social deprivation, hunger, or physical abuse. Instead, we’ve created the conditions for those things to occur at embarrassingly high rates, and we prosecute the unlucky after the fact. The children are simply collateral damage.

We stood at our patient’s bedside and tried to imagine a happy future. Even without his medical problems, he would likely need a major investment of resources in order to thrive. Where would those resources come from? I saw the hospital crib, metal bars on all sides and a thick plastic roof to prevent escape, as a metaphor. Later, I took the elevator down and overheard a snippet of conversation between two residents. One of them asked the other, “How do you know when you’ve burned out?” The other replied, “I don’t know, I guess when you’ve stopped burning.” Burnout is a hot topic in medicine, and some may assume the reasons are obvious: long hours and intellectually demanding work. In reality, those drivers may be less important than the repeated exposure to profound injustice inherent to the practice of medicine in our country.

As hospitalists, we address acute decompensation in our patients and send them back out into the world knowing there will soon be a next time. We also know that the next time might be preventable, if only … This cycle sometimes feels inexorable, but it can also prompt us to think about our obligation to work toward a more just society. We have to imagine a better future even as we struggle to believe it is on the way.

Most of our hospitals are trying to help. They have community-engagement programs, they purchase housing for homeless patients, they provide large amounts of uncompensated care and sometimes operate at a loss. Yet none of this addresses the root cause of the problem. Medicine, either in the form of an institution or a doctor, can’t replace a just society, but the truth of this fact does not mean we should not try.

Pediatrics has always been a field disposed toward advocacy. The origin of our largest professional organization in the United States was the intraprofessional conflict within the American Medical Association (AMA) over the Sheppard-Towner Act of 1921, one of this country’s first attempts to address the social determinants of health with legislation.³ The American Academy of Pediatrics was formed in 1930 after the AMA House of Delegates rebuked the Pediatric section for advocating for continuance of the act during the late 1920s.³ Perhaps what Pediatrics has to teach the rest of medicine is the necessity of making advocacy a part of our professional identity. And perhaps that’s the reason that so many pediatricians are still burning and not burned out.

Michael Hickson was a 46-year-old with a severe acquired disability whose COVID-19 course involved multisystem organ failure, a court-appointed guardian, hospice care, discontinued fluids and tube feeds, and eventual death. While some details have been released by the hospital,¹ the recorded conversation between Mr. Hickson’s wife and a treating physician has been shared widely in disability communities.

Physician: “Right now, his quality of life—he doesn’t have much of one.”

Spouse: “What do you mean? Because he’s paralyzed with a brain injury, he doesn’t have a quality of life?”

Physician: “Correct.”

As physiatrists—physicians for patients with disabilities—we heard those words with heavy hearts and sunken stomachs. We can only imagine the anger, fear, and betrayal felt by our patients and other people with disabilities. Or perhaps they feel vindicated, that the quiet sentiments were finally said out loud. The recording expresses what people with disabilities long suspected: physicians don’t always value the lives of persons with disabilities the way they value the nondisabled. Research confirms this.^2-4 The privilege of the nondisabled is often expressed as “I would never want to live like that.” People make personal judgments about how they would feel in somebody else’s situation. The usually quiet sentiment, this time said aloud and recorded—“He doesn’t have much [quality of life]”—showed how physicians’ judgments and biases can have a grave impact on others, especially people with disabilities.

Stereotypes, assumptions, and biases about the quality of life of people with disabilities are pervasive throughout healthcare, resulting in the devaluation and disparate treatment of people with disabilities.⁵ Healthcare providers are not exempt from deficit-based perspectives about people with disabilities,⁶ and discrimination ensues when healthcare providers make critical decisions from these perspectives.⁵ Ableist biases are underrecognized among physicians, who often misperceive quality of life for people with disabilities as poor, and fail to recognize that medical judgments can be biased accordingly.⁵ Consequently, necessary care can be withheld or withdrawn inappropriately.⁵ An estimated 25% of adults in the United States self-report disability; furthermore, disability is highly correlated with age as well as socioeconomic disadvantages.⁷ There is also extensive evidence that, as a population, people with disabilities experience healthcare disparities.⁸ Bias against people with disabilities serves to both restrict and reduce access to healthcare.⁹

The consequences of the pandemic have disproportionally affected the Black community, in terms of both economic and disease burden. Mr. Hickson, a Black man with disabilities who contracted COVID-19, personifies the intersection of race and disability and demands our concern and attention as physicians. We must appreciate the intrinsic worth of all people and populations, and seek to understand and respect their capacity to be active agents in their own lives, making their own decisions about their quality of life. The lives of Black people have value, but movements such as Black Lives Matter have been needed to highlight this truth, and there still needs to be meaningful action beyond rhetoric. The lives of people with disabilities have value. Healthcare systems and providers similarly need to acknowledge and act in a way that honors the intrinsic worth of people with disabilities.

People with disabilities face long-standing systemic barriers to equitable healthcare,¹⁰ as do Black people. During the pandemic, widespread alarm was raised about individual and structural racism in medicine, just as numerous disability rights organizations raised concerns that ableism would lead to undertreatment during the COVID-19 crisis, worsening existing healthcare inequities. In response, the US Department of Health and Human Services Office for Civil Rights in Action released a bulletin that stated, “In this time of emergency, the laudable goal of providing care quickly and efficiently must be guided by the fundamental principles of fairness, equality, and compassion that animate our civil rights laws. This is particularly true with respect to the treatment of persons with disabilities during medical emergencies as they possess the same dignity and worth as everyone else.”¹¹ Using the presence of disabilities to limit or deny a person’s access to health care constitutes a clear violation of nondiscrimination law.¹² Hospitals and providers should not limit the care offered to people with disabilities because of their disabilities or utilize quality-of-life judgments when deciding whether or not to provide care.¹² While the hospital where Michael Hickson died released a statement claiming that they did not consider his disability status as part of their treatment decision-making, the recorded words of the physician suggest otherwise.

The impact of our words and actions, and not the underlying intent, most affects patients’, families’, and communities’ trust in the institution of medicine, represented by individual providers. The hospital statement indicated “it was not medically possible to save [Mr. Hickson].”¹ The phrase “not medically possible” ties Mr. Hickson’s case to one of futility; however, the recording was about quality of life, not futility. The National Council on Disability found that subjective quality-of-life assumptions influence medical futility decisions.⁵ While the intent of withdrawing care from Mr. Hickson may have been related to futility, the consequences of this decision are far-reaching as people with disabilities have reason to question whether someone else’s judgment about the quality and worth of their life will lead to loss of their life.

Emphasizing perceived quality of life in making treatment decisions, as was implied for Mr. Hickson, is not a rare event and is one that is likely more common when health systems are stressed. Despite having policies and procedures to follow, biases creep into treatment decisions. In Oregon, for example, multiple cases of disability discrimination during the pandemic were brought to the attention of the state Senate by Disability Rights Oregon.^13,14

Physicians and healthcare leaders must consider the unique needs of the disability community through health equity efforts in the COVID-19 response. There must be universally accessible approaches when planning and implementing a COVID response to increase impact and ensure systems are reaching all underserved communities. For healthcare institutions and hospitals, disability equity must be emphasized in the development and implementation of COVID-19 policies. The exclusion of people with disabilities from decisions about people with disabilities is problematic. This systemic exclusion means that ableist beliefs and policies are often unchallenged.¹⁵ Including people with disabilities on committees creating crisis standards of care protocols or other policies that may purposefully or unintentionally discriminate against people with disabilities is an important step.¹⁶ Representation matters, and people with disabilities must be central in the development of all health equity strategies during a pandemic. Furthermore, when system-level decision algorithms exist that value the life of people with disabilities, clinician biases are minimized, leading to more equitable care.

Examples of strategies include accessible formats for essential COVID-19-related communications, such as American Sign Language, large print, or screen reading technology. We must acknowledge that necessary universal mask policies can generate communication barriers for people reading lips. Hospitals and clinics have rapidly expanded virtual care and telemedicine to improve access. This has enhanced access to care for many people with mobility disability, but can exacerbate disparities for those with vision, hearing, communication, or intellectual disability. To better manage this issue, tailored strategies, such as live closed captioning or digital patient navigators, can be implemented.

Additionally, a person with a disability has the legal right to be accompanied by a designated essential support person. Hospital visitor policies must become less restrictive or enable exceptions when a person with a disability requires their personal care attendant. When it comes to outcome data, it is important to highlight the need for better collection of disability data that can be used to identify inequities as well as monitor outcomes of treatment.

As previously acknowledged, people without disabilities tend to have negative attitudes (both implicit and explicit) toward people with disabilities. These attitudes are re-enforced by societal-level institutions, policies, and structures that marginalize people with disabilities.¹⁷ We call on all physicians and those working in healthcare to question their biases. When you consider quality of life in your decision-making, ask yourself, “whose life?” Recognize and honor the personal, social, and cultural contexts that affect how an individual experiences “quality of life.” Unless the answer to “whose life?” is your own or that of your incapacitated dependent, it is not your place to make “quality of life” judgments. You can and should describe potential outcomes at the physiological or activity level, but leave quality-of-life decisions where they belong—with the individual or their designated representative.

Social media activity in the disability community indicates that Mr. Hickson’s story is perceived, regardless of the provider’s and healthcare system’s intentions, to be yet another breach of trust by the medical system. It is not the burden of the oppressed and betrayed to repair a broken relationship. It is our obligation, as individual physicians and the greater medical institution, to provide care that demonstrates the value and worth of people with disabilities. An imperative step toward equitable care for people with disabilities is to recognize and address our ableist biases.

Michael Hickson was a 46-year-old with a severe acquired disability whose COVID-19 course involved multisystem organ failure, a court-appointed guardian, hospice care, discontinued fluids and tube feeds, and eventual death. While some details have been released by the hospital,¹ the recorded conversation between Mr. Hickson’s wife and a treating physician has been shared widely in disability communities.

Physician: “Right now, his quality of life—he doesn’t have much of one.”

Spouse: “What do you mean? Because he’s paralyzed with a brain injury, he doesn’t have a quality of life?”

Physician: “Correct.”

As physiatrists—physicians for patients with disabilities—we heard those words with heavy hearts and sunken stomachs. We can only imagine the anger, fear, and betrayal felt by our patients and other people with disabilities. Or perhaps they feel vindicated, that the quiet sentiments were finally said out loud. The recording expresses what people with disabilities long suspected: physicians don’t always value the lives of persons with disabilities the way they value the nondisabled. Research confirms this.^2-4 The privilege of the nondisabled is often expressed as “I would never want to live like that.” People make personal judgments about how they would feel in somebody else’s situation. The usually quiet sentiment, this time said aloud and recorded—“He doesn’t have much [quality of life]”—showed how physicians’ judgments and biases can have a grave impact on others, especially people with disabilities.

Stereotypes, assumptions, and biases about the quality of life of people with disabilities are pervasive throughout healthcare, resulting in the devaluation and disparate treatment of people with disabilities.⁵ Healthcare providers are not exempt from deficit-based perspectives about people with disabilities,⁶ and discrimination ensues when healthcare providers make critical decisions from these perspectives.⁵ Ableist biases are underrecognized among physicians, who often misperceive quality of life for people with disabilities as poor, and fail to recognize that medical judgments can be biased accordingly.⁵ Consequently, necessary care can be withheld or withdrawn inappropriately.⁵ An estimated 25% of adults in the United States self-report disability; furthermore, disability is highly correlated with age as well as socioeconomic disadvantages.⁷ There is also extensive evidence that, as a population, people with disabilities experience healthcare disparities.⁸ Bias against people with disabilities serves to both restrict and reduce access to healthcare.⁹

The consequences of the pandemic have disproportionally affected the Black community, in terms of both economic and disease burden. Mr. Hickson, a Black man with disabilities who contracted COVID-19, personifies the intersection of race and disability and demands our concern and attention as physicians. We must appreciate the intrinsic worth of all people and populations, and seek to understand and respect their capacity to be active agents in their own lives, making their own decisions about their quality of life. The lives of Black people have value, but movements such as Black Lives Matter have been needed to highlight this truth, and there still needs to be meaningful action beyond rhetoric. The lives of people with disabilities have value. Healthcare systems and providers similarly need to acknowledge and act in a way that honors the intrinsic worth of people with disabilities.

People with disabilities face long-standing systemic barriers to equitable healthcare,¹⁰ as do Black people. During the pandemic, widespread alarm was raised about individual and structural racism in medicine, just as numerous disability rights organizations raised concerns that ableism would lead to undertreatment during the COVID-19 crisis, worsening existing healthcare inequities. In response, the US Department of Health and Human Services Office for Civil Rights in Action released a bulletin that stated, “In this time of emergency, the laudable goal of providing care quickly and efficiently must be guided by the fundamental principles of fairness, equality, and compassion that animate our civil rights laws. This is particularly true with respect to the treatment of persons with disabilities during medical emergencies as they possess the same dignity and worth as everyone else.”¹¹ Using the presence of disabilities to limit or deny a person’s access to health care constitutes a clear violation of nondiscrimination law.¹² Hospitals and providers should not limit the care offered to people with disabilities because of their disabilities or utilize quality-of-life judgments when deciding whether or not to provide care.¹² While the hospital where Michael Hickson died released a statement claiming that they did not consider his disability status as part of their treatment decision-making, the recorded words of the physician suggest otherwise.

The impact of our words and actions, and not the underlying intent, most affects patients’, families’, and communities’ trust in the institution of medicine, represented by individual providers. The hospital statement indicated “it was not medically possible to save [Mr. Hickson].”¹ The phrase “not medically possible” ties Mr. Hickson’s case to one of futility; however, the recording was about quality of life, not futility. The National Council on Disability found that subjective quality-of-life assumptions influence medical futility decisions.⁵ While the intent of withdrawing care from Mr. Hickson may have been related to futility, the consequences of this decision are far-reaching as people with disabilities have reason to question whether someone else’s judgment about the quality and worth of their life will lead to loss of their life.

Emphasizing perceived quality of life in making treatment decisions, as was implied for Mr. Hickson, is not a rare event and is one that is likely more common when health systems are stressed. Despite having policies and procedures to follow, biases creep into treatment decisions. In Oregon, for example, multiple cases of disability discrimination during the pandemic were brought to the attention of the state Senate by Disability Rights Oregon.^13,14

Physicians and healthcare leaders must consider the unique needs of the disability community through health equity efforts in the COVID-19 response. There must be universally accessible approaches when planning and implementing a COVID response to increase impact and ensure systems are reaching all underserved communities. For healthcare institutions and hospitals, disability equity must be emphasized in the development and implementation of COVID-19 policies. The exclusion of people with disabilities from decisions about people with disabilities is problematic. This systemic exclusion means that ableist beliefs and policies are often unchallenged.¹⁵ Including people with disabilities on committees creating crisis standards of care protocols or other policies that may purposefully or unintentionally discriminate against people with disabilities is an important step.¹⁶ Representation matters, and people with disabilities must be central in the development of all health equity strategies during a pandemic. Furthermore, when system-level decision algorithms exist that value the life of people with disabilities, clinician biases are minimized, leading to more equitable care.

Examples of strategies include accessible formats for essential COVID-19-related communications, such as American Sign Language, large print, or screen reading technology. We must acknowledge that necessary universal mask policies can generate communication barriers for people reading lips. Hospitals and clinics have rapidly expanded virtual care and telemedicine to improve access. This has enhanced access to care for many people with mobility disability, but can exacerbate disparities for those with vision, hearing, communication, or intellectual disability. To better manage this issue, tailored strategies, such as live closed captioning or digital patient navigators, can be implemented.

Additionally, a person with a disability has the legal right to be accompanied by a designated essential support person. Hospital visitor policies must become less restrictive or enable exceptions when a person with a disability requires their personal care attendant. When it comes to outcome data, it is important to highlight the need for better collection of disability data that can be used to identify inequities as well as monitor outcomes of treatment.

As previously acknowledged, people without disabilities tend to have negative attitudes (both implicit and explicit) toward people with disabilities. These attitudes are re-enforced by societal-level institutions, policies, and structures that marginalize people with disabilities.¹⁷ We call on all physicians and those working in healthcare to question their biases. When you consider quality of life in your decision-making, ask yourself, “whose life?” Recognize and honor the personal, social, and cultural contexts that affect how an individual experiences “quality of life.” Unless the answer to “whose life?” is your own or that of your incapacitated dependent, it is not your place to make “quality of life” judgments. You can and should describe potential outcomes at the physiological or activity level, but leave quality-of-life decisions where they belong—with the individual or their designated representative.

Social media activity in the disability community indicates that Mr. Hickson’s story is perceived, regardless of the provider’s and healthcare system’s intentions, to be yet another breach of trust by the medical system. It is not the burden of the oppressed and betrayed to repair a broken relationship. It is our obligation, as individual physicians and the greater medical institution, to provide care that demonstrates the value and worth of people with disabilities. An imperative step toward equitable care for people with disabilities is to recognize and address our ableist biases.

Michael Hickson was a 46-year-old with a severe acquired disability whose COVID-19 course involved multisystem organ failure, a court-appointed guardian, hospice care, discontinued fluids and tube feeds, and eventual death. While some details have been released by the hospital,¹ the recorded conversation between Mr. Hickson’s wife and a treating physician has been shared widely in disability communities.

Physician: “Right now, his quality of life—he doesn’t have much of one.”

Spouse: “What do you mean? Because he’s paralyzed with a brain injury, he doesn’t have a quality of life?”

Physician: “Correct.”

As physiatrists—physicians for patients with disabilities—we heard those words with heavy hearts and sunken stomachs. We can only imagine the anger, fear, and betrayal felt by our patients and other people with disabilities. Or perhaps they feel vindicated, that the quiet sentiments were finally said out loud. The recording expresses what people with disabilities long suspected: physicians don’t always value the lives of persons with disabilities the way they value the nondisabled. Research confirms this.^2-4 The privilege of the nondisabled is often expressed as “I would never want to live like that.” People make personal judgments about how they would feel in somebody else’s situation. The usually quiet sentiment, this time said aloud and recorded—“He doesn’t have much [quality of life]”—showed how physicians’ judgments and biases can have a grave impact on others, especially people with disabilities.

Stereotypes, assumptions, and biases about the quality of life of people with disabilities are pervasive throughout healthcare, resulting in the devaluation and disparate treatment of people with disabilities.⁵ Healthcare providers are not exempt from deficit-based perspectives about people with disabilities,⁶ and discrimination ensues when healthcare providers make critical decisions from these perspectives.⁵ Ableist biases are underrecognized among physicians, who often misperceive quality of life for people with disabilities as poor, and fail to recognize that medical judgments can be biased accordingly.⁵ Consequently, necessary care can be withheld or withdrawn inappropriately.⁵ An estimated 25% of adults in the United States self-report disability; furthermore, disability is highly correlated with age as well as socioeconomic disadvantages.⁷ There is also extensive evidence that, as a population, people with disabilities experience healthcare disparities.⁸ Bias against people with disabilities serves to both restrict and reduce access to healthcare.⁹

The consequences of the pandemic have disproportionally affected the Black community, in terms of both economic and disease burden. Mr. Hickson, a Black man with disabilities who contracted COVID-19, personifies the intersection of race and disability and demands our concern and attention as physicians. We must appreciate the intrinsic worth of all people and populations, and seek to understand and respect their capacity to be active agents in their own lives, making their own decisions about their quality of life. The lives of Black people have value, but movements such as Black Lives Matter have been needed to highlight this truth, and there still needs to be meaningful action beyond rhetoric. The lives of people with disabilities have value. Healthcare systems and providers similarly need to acknowledge and act in a way that honors the intrinsic worth of people with disabilities.

People with disabilities face long-standing systemic barriers to equitable healthcare,¹⁰ as do Black people. During the pandemic, widespread alarm was raised about individual and structural racism in medicine, just as numerous disability rights organizations raised concerns that ableism would lead to undertreatment during the COVID-19 crisis, worsening existing healthcare inequities. In response, the US Department of Health and Human Services Office for Civil Rights in Action released a bulletin that stated, “In this time of emergency, the laudable goal of providing care quickly and efficiently must be guided by the fundamental principles of fairness, equality, and compassion that animate our civil rights laws. This is particularly true with respect to the treatment of persons with disabilities during medical emergencies as they possess the same dignity and worth as everyone else.”¹¹ Using the presence of disabilities to limit or deny a person’s access to health care constitutes a clear violation of nondiscrimination law.¹² Hospitals and providers should not limit the care offered to people with disabilities because of their disabilities or utilize quality-of-life judgments when deciding whether or not to provide care.¹² While the hospital where Michael Hickson died released a statement claiming that they did not consider his disability status as part of their treatment decision-making, the recorded words of the physician suggest otherwise.

The impact of our words and actions, and not the underlying intent, most affects patients’, families’, and communities’ trust in the institution of medicine, represented by individual providers. The hospital statement indicated “it was not medically possible to save [Mr. Hickson].”¹ The phrase “not medically possible” ties Mr. Hickson’s case to one of futility; however, the recording was about quality of life, not futility. The National Council on Disability found that subjective quality-of-life assumptions influence medical futility decisions.⁵ While the intent of withdrawing care from Mr. Hickson may have been related to futility, the consequences of this decision are far-reaching as people with disabilities have reason to question whether someone else’s judgment about the quality and worth of their life will lead to loss of their life.

Emphasizing perceived quality of life in making treatment decisions, as was implied for Mr. Hickson, is not a rare event and is one that is likely more common when health systems are stressed. Despite having policies and procedures to follow, biases creep into treatment decisions. In Oregon, for example, multiple cases of disability discrimination during the pandemic were brought to the attention of the state Senate by Disability Rights Oregon.^13,14

Physicians and healthcare leaders must consider the unique needs of the disability community through health equity efforts in the COVID-19 response. There must be universally accessible approaches when planning and implementing a COVID response to increase impact and ensure systems are reaching all underserved communities. For healthcare institutions and hospitals, disability equity must be emphasized in the development and implementation of COVID-19 policies. The exclusion of people with disabilities from decisions about people with disabilities is problematic. This systemic exclusion means that ableist beliefs and policies are often unchallenged.¹⁵ Including people with disabilities on committees creating crisis standards of care protocols or other policies that may purposefully or unintentionally discriminate against people with disabilities is an important step.¹⁶ Representation matters, and people with disabilities must be central in the development of all health equity strategies during a pandemic. Furthermore, when system-level decision algorithms exist that value the life of people with disabilities, clinician biases are minimized, leading to more equitable care.

Examples of strategies include accessible formats for essential COVID-19-related communications, such as American Sign Language, large print, or screen reading technology. We must acknowledge that necessary universal mask policies can generate communication barriers for people reading lips. Hospitals and clinics have rapidly expanded virtual care and telemedicine to improve access. This has enhanced access to care for many people with mobility disability, but can exacerbate disparities for those with vision, hearing, communication, or intellectual disability. To better manage this issue, tailored strategies, such as live closed captioning or digital patient navigators, can be implemented.

Additionally, a person with a disability has the legal right to be accompanied by a designated essential support person. Hospital visitor policies must become less restrictive or enable exceptions when a person with a disability requires their personal care attendant. When it comes to outcome data, it is important to highlight the need for better collection of disability data that can be used to identify inequities as well as monitor outcomes of treatment.

As previously acknowledged, people without disabilities tend to have negative attitudes (both implicit and explicit) toward people with disabilities. These attitudes are re-enforced by societal-level institutions, policies, and structures that marginalize people with disabilities.¹⁷ We call on all physicians and those working in healthcare to question their biases. When you consider quality of life in your decision-making, ask yourself, “whose life?” Recognize and honor the personal, social, and cultural contexts that affect how an individual experiences “quality of life.” Unless the answer to “whose life?” is your own or that of your incapacitated dependent, it is not your place to make “quality of life” judgments. You can and should describe potential outcomes at the physiological or activity level, but leave quality-of-life decisions where they belong—with the individual or their designated representative.

Social media activity in the disability community indicates that Mr. Hickson’s story is perceived, regardless of the provider’s and healthcare system’s intentions, to be yet another breach of trust by the medical system. It is not the burden of the oppressed and betrayed to repair a broken relationship. It is our obligation, as individual physicians and the greater medical institution, to provide care that demonstrates the value and worth of people with disabilities. An imperative step toward equitable care for people with disabilities is to recognize and address our ableist biases.