179 CRITICAL CARE MEDICINE JANUARY, 1994

The Darkside: Appeasing or Confronting?

To the Editor: Dr. Jellinek et al. (1) wrote a very insightful and useful

article regarding "darkside" responses to pediatric critical care fellowship. We agree fully with the educational approaches the authors offer.

We would like to offer the view that the darkside, although expected, is neither normal nor inevitable. We believe the darkside develops from ambiguous demands in critical care, poorly developed decision-making processes for medical emergencies, and over-emphasis on outcome for individual critical care situations.

We believe critical care has only two demands: a) the provision of tissue oxygen delivery and b) the duty to act. To identify oxygen delivery during covert periods of compensated system dysfunction requires sensors and monitors with their own sets of fallibility. Fluency to recognize all patterns of dysfunction requires extensive experience and cannot be expected. However, we can work toward developing fluency in more covert and less overt dysfunctional states. This fluency may be the actual goal of critical care fellowships.

"We are only responsible for delivering oxygen to the tissues, not for consuming it" (Richard Mitchell, Chief; Chalfant Valley [Mono County] Fire Department, CA) Once the patient enters the medical environment, our job may be more like damage control followed by physiologic support as the tissue injury resolves.

Once the critical situation or disease is identified, the practitioner has a duty to act toward intervention-not a duty to cure or succeed, not a duty to act toward gaining physiologic control of the patient. We cannot control the patient's response to disease or our interventions, although we may have some influence. We must not interchange the concept of control with that of influence.

Decision-making in medical emergencies evolved from a more deterministic approach of medicine. Bayesian estimation theory is used when some element of chance or risk influences decision-making. None of this theory prepares us for decision-making in the more stochastic situation of resuscitations (2). In these situations, response to therapy guides further therapy as a "different" patient is created each time. The "sensed" patient, or the patient we evaluate for purposes of management, does not exist later for re- view. Only the "monitored" patient does; this patient is the patient reconstructed later from monitored and recorded data and caregiver notes for diagnosis, heuristics, or legal reasons. The two patients are not identical. Response to therapy as a decision-making technique has more in common with techniques used by public safety services (fire service and law enforcement).

Individual outcomes are problematic compared with systems outcomes. How much success or failure is the result of teamwork, resources, constraints; how much is the result of underlying physiology and pathophysiology; and how much is the result of therapeutic decisions and interventions?

One should not equate outcome with the value of self- worth (3). Intensivists expect all-or-nothing perfectionist responses for outcome which they equate with their self- esteem. Heroic "saves" remind us of how good it is to be in

control. However, "losses" decrease our self-esteem. If we were in control and responsible for the saves, we must have been in control and responsible for the losses. This responsibility comes not only from within the "victim" fellow but from supervisors. Medicine has a phrase "feces flow downhill." However, a good supervisor should protect workers from the downhill slide of feculent matter. A good supervisor should not fault-find and criticize to the point of detriment. To do otherwise encourages the darkside in fellows, while transferring it from supervisors.

This concept also assumes that effort is equivalent to ability. If one is to use "failure" as a heuristic tool, it is important to identify that the cause of the alleged failure is from effort, not ability. Such misattribution to ability impedes development because of the difficulty in changing one's ability. One can, however, change one's effort.

Expectations in critical care abound. There are those expectations we place on ourselves and others. There are those expectations that others place on us. Rarely are these expectations realistic and achievable. More commonly, expectations are preplanned failures. Identifying realistic expectations has been a goal of much of critical care re- search and ethics (should we? vs. could we?). We can show empathy to our patients and their families. Let's not confuse that with detachment from the disease process. We do not infect people with Meningococcus. We do not put 2-yr-old children in swimming pools. We do not cause these diseases. We also have environmental constraints. The intensive care unit is in a constant state of flux, not only from patients but from nurses, respiratory care practitioners, consultants, residents, social workers, etc. All these people have personal agendas that influence performance and are beyond a fellow's leadership control. These constraints influence the fellow's performance in overt and covert ways.

We suggest that, after meeting demands as best we can, we take responsibility only for things we can control. We accept that critical care offers less control than appears with the numerous sensing methodologies.

We suggest that we accept three goals for pediatric critical care: a) short-term chemical and mechanical sup- port for reversible life-threatening disease; b) assistance for families with resolution of death issues when the first goal fails; c) assistance for families in identifying what to do when the first goal fails and they are confused between "should we?" and "could we?"

We suggest universal application of the principles of ethics. The same ethics that apply to patients must apply to colleagues. Nurses, fellows, and other caregivers deserve autonomy and respect for their decisions. They must be treated as if they also have the best interests of the patient in mind. We must use paternalism with caution. Inadequate sensing of covert compensated system dysfunction may lead us to different conclusions the morning after. We cannot say what we would have done in a given situation as, in light of today's monitoring technology, no one really knows what a given situation was.

Daved van Stralen, MD; Ronald M. Perkin, MD; Loma Linda University Children's Hospital, Loma Linda, CA

REFERENCES1. Jellinek MS, Todres ID, Catlin EA, et al: Pediatric intensive care training: Confronting the dark side. Crit Care Med 1993; 21:775-779 2. Mellick LB, van Stralen D, Perkin R: The role of emergency medicine in a teaching hospital: Decision making in an uncon- trolled environment. Am J Emerg Med 1993; 11:187 3. Bums DD: Feeling Good: The New Mood Therapy. New York, Avon Books, 1980, pp 231-257

The author replies: We certainly do not begrudge Drs. van Stralen's and

Perkin's solution to their confrontation of the darkside. In our experience, some aspects of their solution could be considered reductionistic-viewing critically ill children as a series of measurements (especially of oxygen levels), a time sequence, unconscious, with few family issues other than bereavement. Drs. van Stralen and Perkin suggest strict cognitive boundaries, as if these rules are a barrier to limit or resolve inner feelings. Although they cite the role of fire fighters and police officers as a metaphor for appropriate distance and objectivity, these professionals are very vulnerable to the darkside and even more so when in training or when making rapid, subjective judgments in life-and-death situations.

Embedded in van Stralen and Perkin's letter are many statements that betray their deeper understanding of the darkside. They suggest that "one should not equate out- come with value of self-worth...a good supervisor should not fault find." Later, they say "expectations in critical care abound...rarely are they realistic and achievable" and to- ward the end of their letter, they note "all (members of the ICU team) have personal agendas that influence performance and are beyond the control of a fellow's leadership. These constraints will influence the fellow's performance in overt and covert ways." Finally, at the end of their letter, they close using terms such as "autonomy," "respect," "paternalism," and allude to the risk of Monday morning quarterbacking arousing guilt. Like Luke, Darth Vader, and Han Solo, our personal efforts at confronting the darkside continue.

Michael Jellinek, MD; Massachusetts General Hospital, Harvard Medical School, Boston, MA