Podcast – When Professional and Personal Worlds Collide with Liz Crowe

Welcome to the St. Emlyns podcast. I’m Iain Beardsell, and I’m Liz Crowe. Today, we’re going to chat a little bit more about those difficult circumstances in the emergency department or critical care that we sometimes face. Today, we’re going to think about when our personal and professional lives come crashing together, when a patient is suddenly somebody who you know, perhaps who you work with, perhaps even a member of your family.

Over the last few weeks in the intensive care unit, I’ve had a number of instances where someone that I vaguely know or someone that I know very well’s loved one has been admitted. And it’s really made me have to stop and reflect on how we handle those instances when we have someone that we know in the intensive care unit or in the emergency department. At what point do we declare that to our colleagues and consider the way we conduct ourselves, continually asking, “At this moment, am I actually a friend, or am I a doctor, nurse, social worker, or whatever the case may be?”

We’ll use a couple of hypothetical circumstances just to try and expand on this a little bit. I’m sure for many of you listening, you’ve found yourself in this situation where somebody’s come in, you might know them, and people will ask you questions afterwards, or say, “Oh, I hear such and such came in,” or “Goodness, something happened to this person.” Or it may be that you’re emotionally troubled because you’ve seen something really nasty happen to somebody you know.

So let’s start with a hypothetical case. Let’s imagine that through our emergency department, we’ve just had a child, not somebody we particularly know, but a child from the school that one of our children attends. They’ve been involved in a trauma, they’ve needed to go off to the operating room, and then they’re going into intensive care. So they’ve come through my care in the ED, and they’re now being looked after by you as a social worker on the pediatric intensive care unit. We’re getting asked questions about them by the school, friends, and family. How do we handle that situation where those lives collide together?

We really need to pause and think about in that moment, are we professional or are we personal? And it goes both ways. When it is someone from the school, even if you don’t know the family directly, you know the school community. So it’s likely that the school principal, teachers, or just other members of the school community, knowing that you work in that environment, are going to give you a ring and ask you for an update. At that moment, if you are working, particularly on that day, you are actually a professional, and you are bound by confidentiality just like you would be with any other patient. You shouldn’t actually even confirm whether or not the patient is an inpatient without first checking with the family.

And that can be difficult to do. The family really has their own needs at that time, obviously, extremely concerned about their child or their loved one. So it can seem a bit narcissistic to go up and say, “Oh, look, the whole school community is ringing.” I was wondering if it would be okay with you if we release information. So I think often in those first immediate hours, you are 100% professional, and you can’t even confirm. And that makes it difficult, particularly if it’s your best friend who’s ringing up saying, “I know you know they’re in there. It’s just me; I’m your best friend; I’m not going to tell anyone.”

But in that circumstance, the chances of them telling someone are huge. If the family decides that they don’t want that information released or that they want to control the information and you do release it, you could actually find yourself in a great deal of strife professionally and personally. So I think it’s important that you always stop and have a think at that moment, are you professional or personal?

On the flip side, if you have nursing and medical staff coming to you and saying, “Don’t your kids go to that school? What do you know about that family?” and you’re releasing information, are you doing that as a professional or as a personal assessment? If you only know that family within the context of the school community, you probably shouldn’t be giving any personal information because you’ve just done that as a friend, not actually as a professional. So it works both ways and puts you in a very tenuous position.

The best advice is to remember at all times that your first priority is to the patient and to their confidentiality. It can be very tempting when you’re in the know to want to share information, especially when there’s such an outpouring of emotion from people around you and your community. But you really must separate the two and remember the confidentiality by which we all hold ourselves and actually the family trusts you with. You have to find ways in which you can say very politely, “I’m really sorry, I can’t tell you anything.” You may get further pressure, but you have to resist that. It’s hugely important, although it can be difficult.

In a recent instance that I had, the school principal rang, who’s someone who obviously holds a lot of power in your children’s school, and he was saying, “But you know who I am. You know they would want me to know.” And I was saying, “Yes, Father, I do,” because my boys are at a Catholic school. “Yes, Father, I do.” Until I speak to the family and get consent from them to share information with you, I’m not allowed to say anything. I’m bound by my own laws just like you would be in confession. I said to him, “And I’m not prepared to have that conversation with them while they’re in this much crisis.”

Certainly, over the next few days, I was able to speak to the family and say, “This is what was happening.” They were the type of family that was hugely comforted by the thought that the school community was interested and were happy for information to be shared. But until you receive that consent, you are bound by every other realm of confidentiality not to say anything. So keep that thought very close to you when you’re thinking about what you should be talking about and what you should be saying. Because these questions won’t just happen when you’re at work or in work mode, if you like. They’ll happen at the school gate too. You’ve got to be careful not to be caught off guard. It may well be that we like to separate our work and our personal lives, but the truth is that we’re healthcare professionals whether we’re at work or not. So you’ve got to maintain that level of confidentiality.

Liz, how do you deal with the fact that if this child isn’t just a member of the school that your children go to, but actually maybe the son or daughter of somebody that you know who’s a friend? Does that change things?

Yes, it absolutely does. You can’t win this. You have to have a plan. Because you have to have a plan for yourself, for the family, and for your team to ensure that everyone’s needs are met and that you are abiding by the same guidelines that you would for any other patient. When that does happen, you need to declare it straight away. You need to say, “Look, I actually can’t be involved in a professional context in this sense because I know this individual.” Sometimes you can’t do that. If you’re the nurse or the doctor or the paramedic who shows up and someone’s life is in danger, then of course you have to respond. But as soon as you can hand over that responsibility, it’s important to do that.

It’s going to be important for your loved ones who know you because if something goes wrong, you don’t want to be associated with that. Sometimes, despite our best efforts, our greatest skills, things still happen, and obviously, people do die. But you have to do it for yourself so that you’re aware at all times where you’re sitting. I think lots of people can try and believe that there is a way to be both professional and personal. Having recently had these experiences myself, you just can’t. I was really pleased that despite the fact that this particular child was in the ICU for several weeks, I never once looked at her chart. And we have electronic charts. It’s very easy to do, but it’s also very easy to be audited.

Really remind yourself that you have no right to the information if you’re not the professional. So in that instance, I completely excluded myself from ever being the professional involved. But if that’s the case, then you have no access to information. You have no access to electronic records. You have no right to even listen. And as the admission actually became quite protracted and more difficult, I also had to step out of ward rounds when that individual was discussed. And that’s a real challenge to try and stop yourself from knowing things that you’d actually quite like to know because people want more information from you. You have to be really strong in these circumstances.

What we’re saying throughout all of this really is you have to look after the patient and their confidentiality. And you have to look after yourself and protect yourself to an extent. Don’t get yourself into a situation where you could find yourself compromised, whether you’re as strong as you think you might be or just in a moment of weakness where you let something slip. Most of the time, it would be fine, and no one would mind. But once in a career, perhaps it could have devastating effects, not just for you personally but for your patient as well.

I think all of us, when we’re given a hypothetical, believe, “This would be very clear for me. I would know when I’m personal and I would know when I’m professional.” And I would be able to have very strong boundaries. But if there’s someone in your ED frequently or in your ICU frequently, or the admission is quite protracted in the intensive care setting, it gets very difficult because people start to ask your opinions as the friend. The family is saying, “What do the doctors say? What happened in the ward round?” Which is why I had to actuallystep out every day when this person was discussed.

You can’t be both, and it gets very difficult to keep that in mind because there are times that you want to wield a little bit of influence and power. These are your friends or these are your loved ones, and so you want to make sure that the best nurses are there or the greatest registrar is involved. And you can’t. You can’t bring those judgments; you can’t bring that influence. It’s really unfair on the staff and, in actual fact, it’s really unfair on the family as well because then they will be confused about what your role is. And more importantly, it can be really an ethical dilemma for that patient, and it can really tear you apart personally.

So we’ve talked about two different occasions: one where it’s a child or perhaps somebody you know in your community. We’ve also thought a little bit if you’re closer to the patient, perhaps they’re a family member. The last thing I’d like to chat about, if we can, is what you do when it turns out it’s a colleague, perhaps somebody who works in your own emergency department or in your intensive care unit, who is suddenly a patient in your department. Now, this could be anything from an ankle sprain to something more personal. They might have come in with a dodgy rash. It could go to the very extent of that, where they’ve got life-threatening or life-changing injuries.

We’ve both had occasions in the past where we’ve been confronted with colleagues of ours who have had severe injuries or severe medical problems. And you’re surrounded by a nursing team who are also colleagues of that colleague, and you have an emotional environment where you have to try and concentrate on the work you’re doing, yet that can be really difficult. And then in the following days, the colleagues who weren’t there will ask you, “Well, tell me what happened.” So, how on earth can we possibly look after ourselves and our patients in those circumstances?

I think as soon as the level of acuity has settled, whether that means that the individual has died or that the individual is actually stable, the whole team needs to withdraw and talk about how they’re going to move forward and how they’re going to manage the situation. We’ve certainly had a number of times where consultants’ own children have become seriously ill, and we’ve actually called a specific family meeting to say, “In this instance, you are a patient, but you’re not a patient. You’re also a very well-loved colleague, someone that we’ve all got a long-standing relationship with. How are we all going to manage this?”

I’ve certainly been in a situation where one of our doctor’s children came in, and she asked to have a look at all the scans directly. And I said, “I can’t make that decision. I need to go and talk to the doctors.” And we actually really had to sit down with her and say, “As much as we want to, ethically, we can’t until they’ve properly reported on it, and then we need to sit down with you just like we would with any other family.” You know, that was hard; she was quite annoyed with us, but you have to sit down and recognize it, like name it for what it is and say, “This is going to be difficult, so how will we manage that?”

But if you’ve had someone come through, it’s really important that it doesn’t become lunchtime gossip. That patient has as much right to confidentiality as any other patient that comes through our doors. Now, if it is a, you know, maybe a slightly amusing or interesting rash in a very private area, you know, the temptation there, of course, is to have a little bit of a giggle about it with someone behind their back. And you know I’ve got a great sense of humor; I love to laugh, but you just really can’t under these circumstances.

As you said before, Iain, nine times out of ten, it would be okay if you accidentally had a slip, if you talked about it with someone, if someone started having a conversation with you and you were just under the impression that they knew all the details when you shared it. Nine times out of ten, that would be fine. But the one time that it’s not okay, it actually could be really threatening to someone’s career, and that’s why we can just never afford to do it ever.

In my experience, what I’ve found happens is you might see the patient who is also a colleague and look after them, and then the next day, somebody asks you what happened. And I’ve found just the simplest way is to withdraw from those conversations, saying, “I’m really sorry, I can’t talk about it.” I’m sure you’ll find out through other means anyway because usually what happens is that colleague will end up having a friend who goes to see them on the ward. That friend who saw them on the ward is seeing them in a personal situation, and then they can talk about what they’ve seen in the personal capacity but not the professional capacity. And actually, with most colleagues, if it’s going to be information that your department will end up knowing and your colleague is okay with that, many people will find that out without you having to help them find it out. So you don’t need to be part of that conversation. We all know what hospitals are like; this information will get out pretty fast. Withdraw yourself, make sure that you maintain that confidentiality, and just be the professional that you want to be.

Another strategy for that is when you actually sit down with people and say, “Obviously, you’re a really loved member of staff and everyone will want to know how they can help and what they can do. What do you feel comfortable to share? And who in the department would you like to be your spokesperson or the person to coordinate the delivering of casseroles?” Whatever the case may be. And it just gives people back a sense of power about, “This is my information, and I will choose how it’s distributed amongst my friends, and I will choose the people who get to talk about it.” Because inevitably, in any work environment, and hospitals are no different, there are people who are a bit gossipy, and there are people who embellish. I certainly don’t let the truth stand in the way of a good story. It’s important that people feel that when they relay the information, they know that what they want to be told is told in a way that’s true for them.

To have the difficult conversation really early in the piece, hopefully involving the patient if the patient is actually deceased, involving their family, saying, “They’re a really loved colleague; they’re very important to us. We would like to do this as a means of respect and a way to support you. Do you feel comfortable with this?” But it can’t be on our agenda. It has to be at a time and a pacing that works for that family or works for the patient.

The other thing we need to just think about is that actually, if your colleagues find out 48 hours down the line that their friend who they work with has been admitted to the hospital but you didn’t tell them, they might be quite resentful of that. There does need to be another way in which you can get the information to your colleagues while maintaining confidentiality. And in the end, if the patient can choose to do that themselves, that is by far the best way. And most of us would be quite happy to have a couple of visitors and a box of chocolates. And actually, most of the time, we work in environments with hugely supportive friends and colleagues. This isn’t really a downside; it’s just something to think about.

The final circumstance is the tragic one where your colleague comes in, and they’ve suddenly died for whatever reason. You’re surrounded by a team who’ve tried to help with the resuscitation, and that’s been unsuccessful. And you have lying in your resus room, now deceased, somebody who previously you were working with. This is probably and hopefully a zero- or once-in-your-career type occasion, but it is worth thinking about how you might deal with that. Obviously, that would just be such a devastating event for every individual in the department. But in the actual crisis, people do have to put their personal feelings aside, obviously during the resuscitation, and then initially to support your colleague’s loved ones. Because as difficult as it would be for us as colleagues and friends, it would be obviously a horrendous environment for the family.

I think for them to see your level of emotion is fine; most family members feel extremely supported by that. And hopefully, their families or loved ones would have a sense of your work environment and how close your team may be. But then I think you need a department-wide response. I think it’s worth letting management know very quickly what has occurred. You might ask for additional nurses or for people to come and give assistance from other wards so that you can pull as many staff as you can, even momentarily, off the floor to let them know what’s happened, and also to give people just some space to grieve and be shocked and confused or get some details about what’s actually happened. And then you need to have a plan about how you’re going to get that team who was involved in the resuscitation an opportunity to talk, debrief, or spend some time together to reflect on what just happened and what it was like emotionally and physically to have to respond and work on a loved colleague or a known colleague, and how you’re actually going to communicate that out throughout the department. And then, more long term, about memorials and remembering anniversary dates and supporting family members. Because often, when there is a tragedy within a unit, people do really want to respond. And in many personal experiences, teams are amazing and can rally together very quickly to raise money and support.

And it sounds hard to talk about it, but actually, although this is happening to you as a team and a department, you still have a department full of other people who need you. And some of the patients who came to you looking for help and somehow you have to maintain a department that can function

and look after them as well. It’s a huge challenge and one that I think is worth thinking about before it happens. We always talk about practicing how you do resuscitative thoracotomy as you’re driving to work or thinking about how you might do a difficult intubation. But sometimes mentally practicing these difficult emotional situations is really worthwhile too because you could be confronted by this at any time, day or night, and you need to have in your head, especially if you’re leading a department, a plan as to what you might do next.

I really hope it doesn’t happen to you, but as it is with all things in emergency medicine, it’s best to plan ahead just in case it does.

The other important point that you alluded to just then is, of course, obviously, be it in an intensive care environment, an emergency department, or even as a paramedic, there will still be other big demands on you clinically at the time. I think it’s okay to go around to the less ill people in the department and let them know there’s been a crisis and that their care will not be compromised, but that things may be delayed a little bit. And most people will respond to that very warmly and appreciate knowing what’s going on in some vague detail. It just gives everyone a little bit of breathing space, and also if they’re seeing high levels of emotion, they know that it’s not related to their own case, but there is an external thing that’s occurred and that they and their loved ones are safe in your department, but maybe some things will be a little delayed.

So Liz, we’ve talked about three really difficult situations there: looking after a member of your community, looking after somebody who’s close to your family, and then finally talking a little bit about when you might have to look after a colleague. Now in the modern age, information gets out very quickly. We all have access to Twitter and Facebook. There are all sorts of other means that we communicate, not just face-to-face in the department or by somebody ringing you up. We really have to be careful about how we use these other types of social media in these circumstances, don’t we?

Absolutely, and I think it raises a whole new ethical challenge for us as health professionals about what we put on social media, who we accept as friends, and how we use the knowledge that we have at work. So, for instance, in my hospital, it’s a sackable offense to put anything on Facebook, even to say, “Really tragic day at work, one of our long-termers died.” That’s a sackable offense because it has enough information that it could be a breach of confidentiality. We have had a number of really challenging situations. I just had it today, actually, where a patient from about four and a half years ago, her mother, contacted me on Facebook just today to say, “Will you be my friend?” I can’t do that. She’s not my friend; she is a long-term patient’s mother whom I’ve had to work with extensively. So the way I personally handle it, I know some people just delete and don’t engage, but I think that’s been a bit more difficult for me because I often have very long-term counseling relationships with some of our families. And so I direct messaged her back and said, “It’s really lovely to hear from you. Unfortunately, due to our contractual laws under Queensland Health, I’m unable to be friends with people on Facebook. However, I hope you and your family are well, and I think of you often.” It’s a way of keeping the relationship open because there’s no guarantee that her child won’t come back into the intensive care, so you haven’t hurt people’s feelings, but you’ve also been very clear to say, “I’m interested in your well-being, but I’m not your friend.” These sorts of challenges are happening more and more on social media, and we need to be aware of them. And certainly on Twitter, I am sometimes mortified by some of the real detail that people provide about patients or the way people might mock patients they’ve come across during their working day. Some of that is very identifiable, and it’s not only a breach of confidentiality, it’s unethical.

We cannot be patient-identifiable at St. Emlyns. We never, ever, ever use complete patient stories when we’re talking about education. We change bits so that they are not identifiable, and there’s always a temporal gap between when we’ve experienced that and when we start talking about it. Maybe you want to post something about how incredible your department is and how appreciative you are to work where you work, and actually, I think that can be a positive thing for the people you work with, especially if you’ve been confronted by one of these really difficult shifts where you’ve had difficult things happening. But just think, if you were that family member, if you were that patient, what would you want to read about you on social media? The likelihood is, not very much at all, if anything. Just be careful.

But look, social media, we do love it. Obviously, this podcast will be going out through social media, so I think it’s a wonderful resource. But it also adds a level of complexity to the work that we do and also those risks around confidentiality and professional boundaries. It’s always good to have a think about it before it occurs and, again, to have a plan about how you would want to respond or the way you’d want to approach things, because it’s not necessarily always black and white. I think there are huge gray areas, and as the technology develops, we’re going to have to keep stopping and pausing and working out what our new plan is.

So we hope this has been useful and maybe prompted you to think ahead about some of those situations that you may find yourself in in the emergency department or critical care generally or to reflect on situations that have happened to you in the past. Please keep in mind at all times patient confidentiality. These situations can be challenging, and if you find yourself in one of them and you’re not sure what to do, head to your senior clinician or your senior nurse support, whoever it may be in your hospital that you can chat to. Don’t get yourself into a situation without talking to somebody first because you may find that they’ve experienced this in the past and will be able to give you really good advice.

Liz, thank you so much again for joining us on the podcast. I hope you’ll join us again soon, and take care, everybody.