Introduction

Studies have shown that despite advances in patient centered outcomes deficiencies remain in delivering compassionate healthcare [1]. In the US a large proportion of the public believes that the healthcare system is not compassionate [2]. Evidence also points to the fact that physicians miss up to 90% of opportunities to respond to patients with compassion [3]. The ICU is a setting where life and death decisions are made and sensitivity and compassion to the patient and family suffering are most needed. Since doctors enter the demanding field of medicine because they wish to help people and relieve suffering why is there scarcity of compassion in healthcare [4]?

The normative premise for healthcare is that physicians and organizations have a moral responsibility to dispense proper care and act on the basis of particular responsibilities towards their patients [5]. This concept of caring is an essential component of the complex entity of compassion, which in healthcare underpins the relief of suffering and feeling of empathy and connection with other sentient beings [6]. The intention and focus of care and compassion are “sensitivity to suffering in self and others with a commitment to try to alleviate and prevent it” [7]. This concept and its benefits have been recognized in medical as well as spiritual tradition over centuries [8]. In the intensive care unit (ICU), critically ill patients are cared for by a team of physicians and nurses. Recently, the study of compassion has revealed many levels of positive effects on clinical and psychological wellbeing, as well as prosocial and caring behaviors [9].

The emotional burden of suffering in the ICU (of the patients’, as well as their loved ones’) invokes feelings of duty, caring, empathy and compassion which encapsulates the physicians’ role as an altruistic and kind responder motivated by not just humanistic feelings but also the moral ontology of a virtuous physician-healer [10]. Compassionate and caring behaviors result in better outcomes for patients and their families [11]. However, there is an intersection of compassionate care in the ICU, and the complexities surrounding communication, decision making, the role of families as surrogates and complex interpersonal relationships, which disrupts the balance of this moral premise and raises tensions. Studies done on physician compassion from a patient perspective emphasizes the focus on listening and presence, or awareness of the patient’s emotional state [12]. This not only builds trust within the patient physician relationship, but compassionate care also enhances resilience amongst physicians and prevents burnout [13].

To understand how physicians working in the ICU construct their perception of compassionate care we hypothesized that showing scripted video case vignettes with different themes around compassionate care in the ICU can elicit responses that will help achieve this goal. Our aim was to describe compassionate behaviors in the ICU and study factors that enhance and those that drain such behaviors, with an aim to enable recommendations for practice and training.

Methods

This was an observational, qualitative study using video case vignettes and focus group discussions. The Standards for reporting qualitative reports guidelines were used [14]. Participants were invited via email of 2 international critical societies. Informed consent was obtained via email prior to the focus group discussions. Two scripted video vignettes were shown to 3 groups of participants of virtual focus group discussions. These video scenarios were 5 minutes each and were developed using real life scenarios occurring in the ICU. The 2 videos chronicled interactions around the end-of-life care of an African American patient who had expressed previously the desire not to receive non-beneficial life prolonging measures. The ICU attending (male), bedside nurse (female), and a junior (female) resident discussed goals of care which included aggressive measures or goal concordant and compassionate care. In one video the attending was portrayed as compassionate, inclusive, and kind, and conversely in the second video he was shown as distracted, dismissive, and did not appear to care about the patient’s wishes and preferences but wanted to ‘make a bed’ in the ICU. (S1, S2 and S3 Appendices and S1 and S2 videos labeled Compassion and No Compassion using nurse and physician volunteer actors).

These contrasting videos were followed by a general discussion amongst 25 participants in three divided focus groups conducted among participants from different parts of the world and who were members of the European society of intensive care medicine (ESICM) and the Society of critical care medicine (SCCM). Structured prompts were used by the principal investigator who moderated these discussions to elicit responses about compassionate behaviors (or the lack of it) in the ICU. The videos were used to bring out salient aspects of compassionate care and resonate with the participants as examples of the display or the lack of compassion and empathy. Transcripts of all three focus groups were analyzed by thematic analysis and codes were iteratively developed by the study team. Codes were compared and any disagreements were resolved by mutual discussion amongst the study team. Institutional review board approval (2021P000065) was obtained at Beth Israel Deaconess Medical Center, Boston, for this study and participants were invited from the 2 ICU societies online. The virtual focus groups were conducted over an online platform (Zoom®). Most of the participants were physicians, with 1 ICU nurse.

Patient and public involvement

No patient was involved.

Results

20 participants responded to the invitation and 3 separate focus groups were conducted by the principal investigator. After viewing the videos participants agreed that the scenarios resonated with them, and they could recollect encounters whilst working in the ICU like the 2 situations. Both the verbal and non-verbal communication was apparent to the participants, and they reiterated the value of the underlying factors that may lead to such behaviors. These included discussion on the following aspects of the 2 scenarios.

Discussion

This study was aimed at eliciting the various aspects and understanding of compassionate care in the ICU environment and identifying some key hindrances to such care. This study revealed that ICU physicians show intention and believe the moral imperative for compassionate care, however through communication constraints, structural incompetent expectations, and environments (for example, electronic health record demands superseding time spent with a dying patient, or family separation at the time of death during the pandemic), work strain burdens and burnout, these compassionate intentions are drained. These hurdles are manifest in their decisions and clinical choices, interpersonal connection or lack of it, and nonverbal behaviors.

Compassionate care should, therefore, encompass good communication, sensitivity, thoughtful consideration of patients and co-workers and having a humane relation with the patient and involved staff. This study also shows that although ICU physicians share a moral imperative and intention for compassionate care and feel relief and confirmation of their values and convictions in the video depicting compassion. They also relate to the audiovisual depiction of the unpleasant lack of insensitivity and compassionate care shown in the negative video.

The recent COVID-19 pandemic had highlighted existing structural deficits with resulting lack of work life balance which produced unprecedented levels of burnout and indeed unmasking of various levels of stress borne by ICU staff [15]. “This is coupled now in the era of electronic health records, where there are rigorous data to show that health care providers spend more time looking into computer screens than looking their patients in the eyes” [16]. Recent focus on systemic racial and ethnic biases are also embedded in these structural developments in healthcare norms. Yet the role of such structural forces on health and healthcare, which arise from social, economic, and political factors are drivers of poor health outcomes [17]. These disparities also increase the burden on healthcare workers who manage these outcomes [18]. In summary, many aspects of ICU care can be the drivers and drainers of compassionate care. This is similar to findings by critical care nurses who have described that unmet expectations and demands from management and colleagues are hindrances while provision of patient-centred care enhances their capacity for compassion. The pandemic has affected everyone in a negative way, not the least ICU physicians and has magnified existing structural deficits. Structural competency, (i.e. understanding which structures impede or drive the delivery of optimal care), can contribute to understanding one’s own compassion or lack thereof [19]. The current moment in healthcare with this increased awareness of healthcare burdens and structural incompetence, can provide an unprecedented opportunity to shift the working environment and training to comply with the patient and provider demand for compassionate care [20]. This can enhance outcomes for patients and families as well as provide a more satisfying and fulfilling experience for physicians and nurses. In this digital world, one of the key findings is how physicians feel that instead of spending time forming important humane connections with patients and families they need to pay attention to the electronic health record and documentation.

In his book ‘The soul of care: the moral education of a husband and a doctor’ (2019) Professor Kleinman writes “Caregiving is long, hard, unglamorous work—at moments joyous, more often tedious, sometimes agonizing, but it is always rich in meaning [21].” The results of this study resonate with Professor Kleinman’s conclusions that physicians connect with the practical, emotional and moral aspects of caregiving.

Our study had the inherent limitations of a qualitative study which was based on video case vignettes to invoke audio-visual cues for focus group discussions among intensivists from across the world. The discussion was based on reflections of participants and not on real life actions. Qualitative thematic analysis is subject to bias of interpretation [22]. This was mitigated by iterative discussion, constant comparison and coding and recoding. The videos were found to be powerful for eliciting responses, as one participant stated:

“A lot of learning opportunities in the first video, I think, you know, besides addressing the patient’s pain, which I think is also a component of compassion care, I think you guys hit the nail on the head about nonverbal communication. I think when you don’t address, you know, the issues in the room, it makes everybody really uncomfortable. And I think that effect trickles down to patient care. Eye contact is so important. Not just to the staff members, but you know, one of the things I’ve realized when you are sitting with a patient or family really like really connecting with that. It has actually for me, it’s a lot of mental energy, but it’s so powerful.”

Healthy and supportive work environments are imperative to the health and wellbeing of ICU staff as well as patient outcomes [23]. Logistic and systemic changes in the healthcare environment can improve wellbeing and satisfaction. A thorough exploration of emotional distress in relation to communication skills, ethical rounds, and mindfulness might provide an appropriate starting point for the development of further preventive strategies and development of compassionate behaviors. We also can foster compassionate organizational cultures by recognizing the needs of ICU physicians when delivering humanistic care and build on the findings of this study [24]. Such examples would include explicit teaching tools for trainees, clinical programs that encourage acts of compassion, counselling sessions and other interventions focused on enhancing connections with patients and families rather than electronic health records.

Conclusion

It seems that physicians working in extremely stressful conditions share a moral imperative and are inspired by the humanism and compassion that fueled their initial motivation to join physically and mentally demanding healthcare work. However, these sentiments are eroded by the pressures of capacity strain, lack of staff, lack of compassionate skills training, dreariness and perfunctory electronic health record maintenance, and other non-humanistic rituals in healthcare, as these take up the precious time and energy rather spent in forming compassionate connections with patients and their families at times when these actions are most required.

Supporting information

Acknowledgments

I wish to acknowledge the consultation and guidance of Dr. Arthur Kleinman MD, MA Professor of Medical Anthropology, Psychiatry and Global Health and Social Medicine, Harvard University and Harvard Medical School and Dr. B. Subramaniam, Professor of Anesthesiology, Beth Israel Deaconess Medical Center and Director, Sadhguru Center for a Conscious Planet.

We wish to thank Dr. E. Mohamed for transcribing the focus group discussions, and Mr. D. Frobel for help with making the case vignette videos, as well as the actors who were a volunteer nurse and trainee doctor. We also thank the ESICM and SCCM for allowing us to reach out to their members for the focus group discussion, especially Mr. G. Francois and Ms. V. Kumar as well as the 20 participants of the focus groups.

All data generated or analyzed during this study are included in this published article [and its supplementary information files].