 All right. Well, good afternoon, everyone. It's my pleasure to welcome you all to this edition of our noon conference and it's my pleasure to introduce our speaker today, Dr. Benjamin Tolchin for the fellows who heard me pronounce it incorrectly for weeks, it's Tolchin. I've been corrected, so that's the right way to do it. Dr. Tolchin is the director of the Yale New Haven Health System Center for Clinical Ethics and Associate Professor of Neurology at Yale School of Medicine. His research focuses on the impact of crisis standards of care and triage protocols on racial, ethnic and socioeconomic health disparities. In addition, he has clinical and research focus on functional neurological disorders and epilepsy, and he investigates the use of motivational interviewing, smartphone apps and other novel behavioral and technological interventions to improve treatment adherence and outcomes for patients. Dr. Tolchin completed medical school at Harvard Neurology Residency at Columbia and fellowships in medical ethics and clinical neurophysiology and epilepsy at Brigham and Women's Hospital and Harvard Medical School. He has won numerous awards for his research and his publication, and it's really a pleasure for me to welcome him to the McLean Center today. So, Ben, thank you for being here. Thank you, Dr. Anderson. Thank you for your invitation. It's a real honor to be here to share with you some of the work that we've done at Yale in terms of trying to broaden access and awareness of ethics consultation work across the healthcare system. And so I want to speak to you on that topic. Just a couple of disclosures about research funding. So my goals for this talk are that participants will be able to summarize evidence of diverging utilization of ethics consultation services between large teaching hospitals and small community hospitals in the United States. Participants will be able to describe how a hub and spokes model can provide increased access to ethics consultations and small community hospitals affiliated with large academic medical centers. And participants will be able to explain how a hub and spokes model can allow ethical concerns and best practices from both large academic medical centers and small community hospitals to be shared and discussed across a large healthcare system. And so I want to begin, and I know this audience is very aware of the value and purpose of ethics consultations, but I think when we're looking at disparities, it's important to think about, you know, what are the benefits? What is the purpose of the service in question? And in this case, ethics consultations, there is some significant work on the benefits of ethics consultative work. So we all know that complex cases involving uncertainty, disagreement and moral dilemmas arise frequently in acute care hospitals and particularly in intensive care settings. And this negatively impacts both patients and families on the one hand and clinicians and staff on the other. For patients and their families, post-traumatic stress disorder and PTSD symptoms are quite common, particularly in patients who have been through the ICU. For clinicians and staff, moral distress is significantly elevated in acute care hospitals and particularly in ICUs, particularly among nurses. And that moral distress is associated with burnout and leaving ICU positions, which contributes to a significant staffing crisis that is affecting us nationally. Governments, regulatory bodies like the Joint Commission and professional organizations like the American Medical Association mandate ethics committees and ethics consultative services. In the U.S. and other countries, ethics consultations have evolved as the primary formal mechanism to address ethical issues in the clinical setting. The American Society for Bioethics and Humanities publishes guidelines for best practices and certifies clinical ethics consultants with the HECC certification. But are ethics consultations actually effective in addressing these issues? So Natalie Jetet and her team conducted a systematic review in 2018 of outcomes associated with clinical ethics consultations. They identified 16 studies, including seven randomized clinical trials and prospective controlled cohorts and eight retrospective cohorts and overwhelmingly both patients and clinicians, approximately 90% of both patients and clinicians reported that clinical ethics consultations were helpful. Jetet and her team focused on achieving consensus in clinical decision making and they found through a meta-analysis of three studies that cases where clinical ethics consultation were significantly more likely to achieve consensus about the clinical decisions with an odds ratio of four, which is a fairly substantial odds ratio. Jetet's team also looked at resource utilization and specifically length of stay in the ICU and in the hospital among both survivors and non-survivors. And the reason for that is that there was some concern that ethics consultations might shorten length of stay and reduce resource utilization by limiting life sustaining treatments and resulting in patients dying more quickly. In fact, they found in five studies, their meta-analysis demonstrated that there was reduced length of stay both among non-survivors and also among survivors. And that may be a consequence of the increased consensus in clinical decision making that facilitated treatment and discharge from the hospital. So we have fairly robust evidence from multiple studies that clinical ethics consultations are seen as helpful by patients and clinicians that they increase consensus in complex clinical decision making and that they reduce length of stay and resource utilization in both the ICU and the acute care hospital. And so with this information, I think it becomes much more meaningful to look at disparities and Ellen Fox and her team in 2022 published a survey. It was a 2018 survey of 600 hospitals stratified and randomly selected, including both small community hospitals, mid-sized hospitals and large teaching hospitals. And they actually compared the results of their 2018 study to an earlier 2000s survey, which was published in 2007. And so they were able to look at not just the rates of ethics consultation, but also the trajectory of ethics consultation from 2000 to 2018. And what they found was that overall there is a 98% increase in ethics consultations over that time period, but overwhelmingly that growth in ethics consultations is driven by growth in large academic teaching hospitals. So hospitals with 400 beds and more are where you see significant rates of growth in ethics consultation from 2000 to 2018, whereas looking at hospitals with less than 400 beds, there is little or no growth over that two decade period. Now, this is an issue that affects our health care system directly we the Yale New Haven health system includes six hospitals, each of which has its own ethics committee and ethics consultation service. And these hospitals range significantly in size and location in their catchment areas in the demographics of the patient population. It ranges from westerly hospital and westerly Rhode Island with 125 beds a community hospital, not a teaching hospital. There's a mid size hospital bridgeport hospital with 500 beds so with some teaching services, and then there's Yale New Haven hospital with 1541 beds, making it the second largest hospital in the United States included within Yale New Haven hospital is a smaller Yale New Haven Children's Hospital. Each of these hospitals has its own ethics committee, its own ethics consultation service. And since 2018 we've been tracking ethics consultations in these different settings. And what we've found is, if anything an even more extreme divergence than Ellen Fox and her team found since 2018, the number of ethics consults at Yale New Haven hospital has increased from 50 to 239 approximately a five fold increase in consult volume and that has happened during a time when the health care system was able to provide for the first time some protected time some financial support to the ethics consultation service and that has resulted in a more rapid more in depth consultative process our consultation duration has dropped from approximately a week to approximately 24 to 48 hours with response times within one hour and I think you know that the growth in in consultations over the time reflects these changes. At the same time, we have Bridgeport Hospital which is as I mentioned a mid size hospital with 500 beds, and then Greenwich westerly with approximately 200 to 200 beds. And what we're seeing in those smaller hospitals is a much slower rate of growth in ethics consultations or seeing 10 to 20% growth rates there, which which is completely dwarfed by the growth of ethics consultative work at Yale New Haven hospital and is leading to an increasing disparity over time and so we've discussed and thought a lot about how we can provide support to all of the hospitals within within our health care system how we can tap the resources that are available in a large academic medical center and and use those resources to provide the benefits that we've seen that are provided by ethics consultation services across a health care system, including small primary care hospitals. And our our approach what we are in the process of doing now is to build a Center for Clinical Ethics and so what we've done is we've taken those six ethics consultation services and we have organized them under an umbrella organization, a Center for Clinical Ethics, and we've built, in addition to the consultative work, an ethics education program, which provides educational services to clinicians and ethics committee members across the health care system. An ethics quality improvement and research program which provides research resources that are frankly not available in some of the smaller community hospitals, and also an organizational ethics consultation service that all of which operate at the system level to provide support to all six of the hospitals I want to go into depth on on some of these different programs. Before I focus on those programs though I just want to highlight that in addition to the Center for Clinical Ethics we are fortunate to be in a community with multiple organizations that are involved in or adjacent to the clinical ethics and bio ethics fields. So in addition to the Center for Clinical Ethics that we are developing, there is already an interdisciplinary Center for Bioethics which is operates out of the Faculty of Arts and Sciences. The School of Medicine has a program for biomedical ethics which offers twice monthly ethics symposiums and ethics education for medical students. The Law School has a Solomon Center for Health Law and Policy which tackles health policy questions, host symposia and provides education and research. There is an equity research and innovation center which specifically deals with testing and examining disparities in health care outcomes. And there is a community bioethics forum which includes members of the community who are not employed by the university or the health care system who have experience with health care within our network and who have volunteered to provide their perspectives and opinions regarding ethical questions and challenges. And the Center for Clinical Ethics acts as a pathway for the clinical ethics committees and consultation services across the health care system to tap into and use these resources that are found within the university community but which are not necessarily available to all of the hospitals across our state and extending into Rhode Island. So the primary focus of the Center for Clinical Ethics has been ethics education and that's based on a needs assessment that we conducted in 2021 among the six different ethics committees which identified ethics education as the primary gap and obstacle in their ability to provide robust and effective ethics consultations in their hospitals. And ethics education includes connecting clinicians and ethics committee members to programs offered by these other institutions. For example, the Interdisciplinary Center for Bioethics runs a summer institute. And we have worked on arranging for ethics committee members to participate in parts of that summer institute at low or no cost, including in online so that clinicians who don't have the availability during normal clinical hours can participate in that summer institute. The Program for Biomedical Ethics offers twice monthly symposia. Dr. Parker and others have actually spoken at that symposium and we have both and we have encouraged ethics committee members to participate in the symposia both in person and online. But in addition to that, the Center for Clinical Ethics has developed new initiatives of its own. In particular, a system-wide ethics forum and newsletter, a clinical ethics fellowship and clinical ethics electives, ICU walk-rounds and we hope in the future support for ethics committee members who are interested to obtain their HECC certification through the American Society for Bioethics and Humanities. So just to go through those in a little more detail, the system-wide ethics forum and newsletter are opportunities for clinicians and ethicists from hospitals across the healthcare system to share challenging cases and best practices. It is a hybrid in-person and online meeting that facilitates communication across disciplines, including not just physicians, APPs and nurses, but also chaplains, social workers, physical and occupational therapists and perhaps most importantly, community representatives, both those who are involved in the larger hospitals and those who are involved in smaller community hospitals. We have been running a clinical ethics elective for medical students, residents and fellows. This is typically a two-week program, but we have actually just received this month authorization from the our GME committee to start a one-year non-ACGME fellowship. And our plan for this is that it will focus on eight months of clinical and organizational ethics consultation work across the healthcare system. So at all six of those hospitals, it will incorporate a seven-week summer bioethics institute, which is sort of shown here. The fellows will serve as small group instructors in the medical school's first year ethics course on a weekly basis. They will also participate in ethics committee meetings and ethics symposia. They will complete a year-long scholarly project and they will culminate with sitting for the HECC certification via an exam run by the American Society for Bioethics and Humanities. And so we've just gotten approval for this and we're starting to recruit fellows now. Another ethics education initiative that has been piloted on the pediatric side is ICU ethics walk-rounds. This is an opportunity for ICU nurses, respiratory therapists, APPs, physicians and trainees to discuss challenging cases in the ICU. With the goal of identifying and addressing moral distress among ICU staff, increasing specifically nursing access to ethics resources, and facilitating preventive ethics prior to the crises that often trigger a full ethics consultation. As I mentioned, this has been piloted on the pediatric side. Our next step is to expand this to adult medical ICUs and we hope thereafter to continue to expand to the other ICUs in our healthcare system. So I want to now talk a little bit about some of the work that the Quality Improvement Program is doing to support the ethics consultation services. So we have begun to collect feedback via online Qualtrics surveys from clinicians who participate in our clinical ethics consultations. And I want to be clear here, it's not that we think that participant satisfaction is the be-all and end-all of ethics consultation quality or effectiveness, but I think it is one important component of ethics consultation quality and it's something that we want to be able to measure as objectively as we can. And so we have begun that process with a survey among the clinicians. We are currently, we've written a version of the survey for patients and families and we're currently having the patient and family advisory committees in our healthcare system review that draft prior to issuing it to patients and families actually involved in ethics consultations. But I want to highlight here the preliminary data we've gotten from clinicians involved in ethics consultations. And this matches fairly closely, I would say, some of the results from Natalie Jeté's work. So we found that among clinicians over 95% felt that ethics consults provided helpful advice and guidance. Over 90% felt that the ethics consultation service promoted communication among patients, families, surrogates, clinicians and other stakeholders. Interestingly, 45% of clinicians involved in ethics consultations reported that they were experiencing moral distress relating to the topic for which the ethics consultation had been requested. And of those 45%, 100% of those respondents said that the ethics consultation helped them to better understand and address their moral distress. And 100% of clinicians who participated in ethics consults reported that they would recommend an ethics consultation to their colleagues dealing with ethical concerns and dilemmas. And so, you know, those are preliminary results, but I think they establish an important baseline, both for future comparison, we will be able to see when there are decreases in satisfaction with our ethics consultation work and devote resources and support accordingly. We will, as we collect more data, be able to compare different healthcare, different hospitals within our healthcare system and again be able to devote educational and other resources to strengthen consultation services where satisfaction rates are not assigned. And we will also be able to compare clinician satisfaction rates with patient and family satisfaction rates and calibrate our ethics consultative work accordingly. So I want to next turn to some of the organizational ethics consultation work that the Center for Clinical Ethics has been doing on a system level. And this for us is really the newest piece. Ethics education and clinical ethics work are things that have been done in one form or another on our campus and on many campuses for decades. But for us, organizational ethics or preventive ethics, developing ethics related policies to try to ameliorate and avert ethical dilemmas and crises before they arise is something that is new to us. And it really began during the COVID pandemic. And it was back in 2020 where there was a great deal of concern about shortages in healthcare resources that might not meet the needs of the, excuse me, patient population prompted the development of a COVID triage policy and a COVID resuscitation policy. And a number of departments and divisions within our healthcare system reached out to us about shortages that they were either experiencing or anticipating during the COVID pandemic. So we developed a with a blood bank, a blood product scarcity protocol with the cardiothoracic ICU and ECMO protocol. And with the P&T committee, the Pharmacy and Therapeutics Committee, we also undertook organizational ethics consults focused on medications that were receiving expedited FDA approval, but which had limited or no evidence of efficacy. And in particular, that includes Atacanumab and monoclonal antibody for Alzheimer's dementia and Elavidus, a gene therapy for Duchenne's muscular dystrophy. And I don't have time to go into all of these organizational ethics consultations in detail. I think after the talk, there will be some informal discussion and if folks are interested, I'm happy to return to some of these organizational consults and talk through them in a little more detail. But for right now, I want to focus on the work we did around COVID and the concern for scarce resources. So what the first ethics related policy we developed was the Yale COVID triage policy and that was developed as a crisis standard of care in early 2020, when we anticipated that the exigencies of the COVID pandemic might push us from conventional care to contingency or even crisis care in which not all patients would be able to receive the life sustaining treatments that they required. And we developed this policy with the goal of saving the most lives possible and ensuring allocation in a consistent and fair manner. And the initial policy, like many policies at that time, use the sequential organ failure assessment or SOFA score and I know that Dr. Parker and others in this program have extensively studied this work and we have been fortunate to be able to use some of the work coming out of the McLean center in developing this and subsequent policies as I'll describe. For those of you who are not familiar, the sequential organ failure assessment is a 25 point scale predicting mortality and critically ill patients based on quantitative assessments of six organ systems. The use of the SOFA score was initially supported by an early cohort study of 180 to 190 patients in Wuhan, China that found fairly high levels of accuracy in that small cohort. They reported an area under the curve of 0.867 when using the SOFA score to predict mortality which is fairly high accuracy rate. Currently, the SOFA score can be calculated automatically from the electronic medical records, which makes it very appealing in a setting of significant resource scarcity, where clinicians may be in very high demand and may not be able to rely on clinicians to score patients for triage purposes. As Dr. Parker and his colleagues have reported 70% of publicly available crisis standards of care used either the SOFA score or a modified version of the SOFA score during this period. And we know for a fact that at least in one state in Alaska, the SOFA score was actually used to allocate hemodialysis machines among patients in a setting of scarcity. Many of these crisis standards of care that use the SOFA score are still in practice are still in place today, although few of them have actually been activated. And I can I can report that the Connecticut Department of Public Health is actually currently in the process of developing crisis standards of care for our state and is considering the the SOFA score as a potential triage tool. But while in parallel to our development of a triage process that used the SOFA score, we had some significant concerns about both the accuracy of the SOFA score and predicting mortality and potential potential contributions to disparities. And, you know, this is where the Center for Clinical Ethics was able to tap resources available within the university and within the large academic medical center that were not available to smaller community hospitals to test the triage medical before it was ever used as I'm glad to say that we were able to develop a SOFA calculation system within our electronic medical record and deploy it, not for clinical use but for quality improvement use so we were able to examine what would the patients who are being admitted COVID actually score under the SOFA score system and how might that affect the allocation of scarce resources if we were to start allocating resources on the basis of a SOFA score. So, in conjunction with the Equity Research and Innovation Center, we conducted a retrospective cohort study of 2320 patients from March to August of 2020. We recorded SOFA scores on an hourly basis and dichotomized peak scores as either elevated, meaning a score of six or higher or not elevated. Approximately 46% of the patients were non-Hispanic white, 27% were non-Hispanic black, 28% were Hispanic, the median age was 65 and approximately 53% were female. And what we found was that non-Hispanic black patients but not Hispanic patients had greater odds of an elevated SOFA score when compared to non-Hispanic white patients. But, at the same time, when controlling for age, sex and medical comorbidities, we found no significant difference by race and mortality. Nor did we find a difference in ICU transfer rates among patients admitted with COVID. So we concluded that the SOFA score is disproportionately elevated for non-Hispanic black patients hospitalized with COVID, but that does not correlate with an elevated risk of death or ICU transfer. And our concern is that crisis standards of care using the SOFA score for triage will disproportionately restrict access to scarce life-saving resources for non-Hispanic black patients, thereby exacerbating healthcare outcome disparities. And this is strongly, this concern is strongly supported in our minds by the work of the University of Chicago team looking at a pre-COVID EICU cohort. So this is a cohort from multiple ICUs from 2014 to 2015, including patients with a variety of diagnoses. And there also they found that SOFA scores overestimated mortality among black patients compared with white patients. In addition, other cohorts looked at the accuracy of SOFA in predicting mortality. And remember, there was that early small cohort out of Wuhan, China that showed a very high accuracy in predicting mortality using the SOFA score. Unfortunately, subsequent largest cohorts in the United States did not show such high accuracy rates. So a large cohort out of the University of Arizona found that SOFA predicted mortality with an area under the curve of 0.59, which is fairly close to predicting mortality by chance and is significantly lower than predicting mortality based on age alone, on chronologic age alone. In our own COVID cohort of 2,300 patients, we found that SOFA predicted mortality also with less accuracy than age with an area under the curve of 0.679 as compared to an area under the curve of 0.795 for age as a predictor of mortality. This graph here is a calibration curve. This is not a receiver operator curve, but a calibration curve. And the diagonal line shows a perfectly calibrated predictor of mortality. The red line shows age as a predictor of mortality. And it fairly closely matches a perfect predictor, although at higher ages it gives an overly pessimistic prediction of mortality. But in contrast, the blue line shows the predictions of the SOFA score. And what you see is at low SOFA scores an unduly optimistic and inaccurately optimistic prediction of mortality and at higher SOFA scores an inaccurately pessimistic prediction of mortality. Interestingly, when we looked in the EICU cohort, this pre-COVID cohort, we did find that in that setting, SOFA predicted mortality with better accuracy than age. So based on these findings of limited accuracy and disparities by race, our organizational ethics consultation service was able to recommend to the healthcare system administration to deactivate and keep inactive the COVID triage policy, which used the SOFA score. And we developed instead an escalation of care protocol. And this occurred in December of 2021 as the Omicron surge was ramping up, filling up RICUs and resulting particularly in shortages of continuous venous hemophiltration circuits to the point where patients who would normally receive a CVVH circuit for 24 hours a day were being allocated circuits for eight hours so that a single circuit could be rotated among three patients. And we anticipated that going forward, we were going to be unable to provide CVVH and other lifesaving support to patients as the Omicron surge increased. So we worked with the guidance of our healthcare systems legal team to accord with Connecticut's statute on the removal of life support systems and medical orders for life sustaining treatment in order to provide legal protection for clinicians in the absence of an executive order releasing clinicians from legal liability, because that executive order had expired by this point in the pandemic. And we developed a policy that was going to be in place for the period of the public health emergency. The Omicron surge was active for about two months from late December to late February of 2021 to late February of 2022. And the scope of the protocol was that it would apply to any patient where two attending physicians assessed that the patient was in a terminal state, which in Connecticut state law means the final stages of an incurable or irreversible medical condition, which without the administration of a life support system will result in death within a relatively short period to patients who were permanently unconscious or to patients who would be in a terminal state if the intervention in question were indicated. And what the escalation of care protocol allowed attending physicians to do is with two attending physicians making the assessment that the patient was in a terminal state and that the life sustaining intervention in question would be extremely unlikely to be beneficial. It allowed those two attendings to change code status to DNR or DNR-DNI or restrict other life sustaining interventions. Those life sustaining interventions included but were not limited to renal replacement therapy, vasopressor medications, blood transfusion, ECMO or ICU transfer. And what I'll say is, you know, over the course of two months that policy was rarely used. There were, to our knowledge, 26 instances in which the policy was actually implemented out of thousands of patients admitted with COVID during the Omicron surge. But what clinicians reported in subsequent qualitative interviews was that they felt empowered by the existence of the policy to be much more honest and direct in describing prognosis and recommendations to patients, their families and surrogates, and that overwhelmingly patients, families and surrogates were responsive to those more honest and straightforward communications and that goals of care discussions significantly changed as a result of that difference in communication. And that patients were much more likely to choose limited life sustaining interventions of their own accord, choosing a code status of do not resuscitate or do not resuscitate, do not intubate in cases where that was recommended by the medical team. And so in this way, the protocol while used, well actually implemented infrequently, had a profound impact on the goals of care conversations throughout the healthcare system during the Omicron pandemic, and significantly reduced the shortages that we were experiencing early in the pandemic. I want to maintain a little bit of time for questions and answers. So what I'm going to do is skip over other organizational ethics consults that we've worked on, but I'm happy to return to those and speak about those at greater length in the informal conversation that follows. But I want to highlight some takeaway points and then have an opportunity for questions and answers from this group. So patients and clinicians overwhelmingly find ethics consultations to be helpful and ethics consultations are associated with increased consensus in complex medical decision making and decreased length of stay among both survivors and non survivors. At the same time, there's a significant national disparity in access to ethics consultations. These are far more commonly conducted in hospitals of 400 beds or more. And this disparity is increasing nationally and within our healthcare system over recent decades, and particularly over recent years in our healthcare system. As hospitals consolidate into larger interstate healthcare systems, there is an opportunity to integrate local ethics committees into unified centers for clinical ethics with a hub and spokes structure. And a center for clinical ethics can increase access and to ethics expertise, disseminate best practices and share ethical concerns across both large academic medical centers and small community hospitals within a healthcare system. A center for clinical ethics can support local ethics committees with educational initiatives such as electives, fellowships, HTCC certification, research and quality improvement initiatives such as feedback surveys, ethics consultation databases, and through connections to university ethics resources, and also by conducting organizational ethics consultations to establish organizational, to establish ethics policies that may prevent or ameliorate ethics dilemmas and conflicts before they reach a crisis level. With that, I want to acknowledge the group of extraordinary contributors, a large interdisciplinary team who have made this work possible across our healthcare system. I want to thank my family and I want to thank you for your time and attention. And with that, I'll stop and take questions from this group and I'm happy to, if people are interested, to go back to some of the other organizational ethics consultations that we've worked on. Thanks, Ben. That's great. And the amount of work you've done and putting together this center is really inspiring and pooling together all the resources for ethics at Yale, which are diverse, but seems somewhat scattered and your vision of combining everything is fantastic. I have a specific question about your interactions with these local hospital ethics committees for the five other. It didn't really seem like most of them were doing much to piece in your data to be blunt. I mean, I don't know if you can hear me, the Bridgeport hospital. Right. You know, the numbers. We're talking about 20 to 30 consoles for Bridgeport and, you know, 10 to 15 consoles for the other smaller hospitals. You're absolutely right. So is it fair to say that you're really bringing clinical ethics consultations as, as a thing, you know, to these hospitals. Period. And that goes along with Ellen Fox's results that ethics consultation for the smoke community hospitals just really isn't happening in any meaningful way. I think that's exactly right. So what we're seeing, what Fox and her team showed nationally and what we're seeing within our health care system is that there really is not robust ethics consultation work at these smaller community hospitals. There are people who are interested, but that but they express first that they lack education and that's that's why education has been such a focus of our center's work. They, and also they are hampered by a lack of awareness among clinicians of the ethics consultation service and so, you know, I think both educating the folks who are potential members of the consultation service and also educating the clinicians about the availability of ethics consultation services and the purpose of that ethics consultation service is something that we're really tackling right now. And that's that's the point of things like ICU ethics rounds is to raise awareness of ethics issues, not just among not just to provide training for the clinical ethicists, but to raise awareness that this is a service that that can be done and why it might be done and what the benefits might be among the general clinician population. Thanks Ben that I agree with will that was really helpful and I guess one one question that I have again relative to this issue of other hospitals and and all. So, even though there aren't large volumes of ethics consults at other hospitals, are you and the people from Yale New Haven, going out and doing those ethics consults, or, you know, you said there were pre existing committees so how do you assess sort of the quality of care as it were across the system. Yeah, it comes ethics. So that's a great question. What we're trying to do is more than having ethics consultants from the Academic Medical Center going out to the other hospitals is to really build and sustain the ethics capacity of the smaller hospitals. So it's each hospital had its own ethics committee and ethics consultation service, those really varied in their level of both skill and activity. Some were essentially entirely non functional and are just now starting to operate. I think all of them are now functioning and have skilled individuals involved. In terms of assessing outcomes so I think there are a few things that we are starting to survey clinicians who are involved in ethics consultations and so, and we are planning within the next year to start surveying patients and families who are involved in ethics in a different source of feedback around the ethics consultations at different hospitals. We, we're discussing complex cases on a quarterly basis that in our system wide ethics forum so every quarter we have a hybrid meeting where members of all the ethics committees and clinicians that the health, all the hospitals in the healthcare system are able to join together, and we will preferentially present cases from some of the smaller hospitals in order to get feedback from clinicians across the healthcare system and also from ethics experts at the university, who the smaller hospitals might not usually have access to. And then, you know, a third method of feedback has been formal needs assessments conducted among the clinical ethicists themselves and so that's so that's where we were asking ethics committee members, you know what are the obstacles that you perceive in your ability to perform effective and robust ethics consultations and the overwhelming response was number one, a lack of ethics education and number two, a lack of awareness of ethics consultations among clinicians at our hospital and so we're trying to address those two issues. And, you know, I anticipate that a couple of years down the road we will again perform a needs assessment we may identify different challenges that are being faced. So we're looking both formally and informally as we're trying to build up capacity at these other hospitals. One other thing I will say is that we are providing ethics support to consultation services when they encounter particularly complex cases so there will be cases where an ethics case involves, you know, a court hearing which the some of the less experienced ethics consultants and some of the smaller hospitals may not have as much experience conducting a court hearing with a probate court. And so we have been active in providing support when things arise that more complex level. Thanks. It's just a small thing that I'd be interested in this data kind of, you know, per capita divided by number of beds. Yeah. So that's a really interesting question. There is things are less unequal per capita because, you know, Yale New Haven hospitals approximately three times the size of Bridgeport. Right. So you can see that back here that actually wasn't really a much of a per capita disparity. But at this point there is a per capita disparity. And so yes, that definitely does decrease the level level of inequity but does not eliminate it. The, you know, the other thing is, it's not just that any patient transfers from the smaller hospitals to the larger academic medical center the more the more medically complex cases. tend to transfer. So transplant cases, cases that require ECMO, cases that require continuous EEG monitoring or neuro ICU are going to disproportionately transfer from these other hospitals to Yale New Haven hospital. And those cases are the ones that most are most likely to progress to an ethics consultation because they're medically and often socially sometimes psychiatrically complex cases. So there are other factors besides the level of education and awareness. There are also sort of matters of like complexity of the average patient at each of these hospitals that factor into the number of ethics consults done that is another issue. I had a question about your escalation of care policy. You know, which would seem to be a contingency care policy, you know, in the Omicron was awful here as well and gets into this gray zone where you have some patients who have probably a pretty good prognosis from their acute critical illness and renal failure. Who it sounds like you're, you know, you're actively under dialyzing as because you're of a absolute resource limitation of CRT. And it seems like that was the main motivation of this, you know, life support and filling ICU beds. So we were at the point the policy was developed. We were boarding 190 patients in the emergency department. And there were there were significant concerns about the level of care that could be given to ICU level patients in a in the emergency department at that level of of staff. Yeah, I just think it was it's a brilliant realization that the problem often will be if we ever get into crisis scenarios or it was in this very severe contingency care scenario is the patients who are currently receiving life support right who have very poor prognosis very unlikely to survive but nevertheless are using a CRT circuit so or other forms of life support so it's not in those 26 cases. How many times was at the end of the day, life support withdrawn over the objections of the surrogates, you know, and I mean you don't have to answer that specifically but I assume that did happen at some point. Yeah, so that's what those 26 cases were there were 26 cases where life support was either withheld or withdrawn over the objection of the surrogate it was always the surrogate in all 26 of those cases. There were many more cases where clinicians reported that they were able to have more frank discussions that led families and other surrogates to voluntarily deescalate invasive life sustaining treatments. I would say the, the overwhelming majority of those cases were were patients who had already had a trial of ICU care. So one thing that was nice about the escalation care protocol, as opposed to, you know, a sofa based protocol was that it gave clinicians the ability to try these interventions and, you know, and then make a determination of whether or not the patient was in a terminal state, as opposed to having to predict prior to the initiation of ventilation or CVVH or other life sustaining treatments. And so, in the overwhelming majority of cases where life sustaining treatment were withheld or withdrawn, they fairly aggressive invasive life sustaining treatment in the ICU had already been provided for a significant period of time. But then there were discussions about limiting or withdrawing some of that care. Yeah, right. It gets to our ability to prognosticate in a triage scenario before starting life support is very bad and sofas horrendous as you showed. Obviously we do work to develop better triage scores, partly with my groups working on now in that scenario, but I feel like yeah this these types of decisions. When we can have much better prognostic certainly because the patient's been critically ill for a while we know what's going on. That's when sofas AUC goes up, etc. And they're better better scores and so forth. So that's yeah I mean I think, but the hard part about this is is that for health systems to admit that the people who are getting split CRT time or getting bored in the ER are being hard, right. Like, that's a problem contingency care is you can kind of close your eyes and pretend like everything's fine. And it's really not. Right. So this is great that this happened. Definitely ethical. I mean, it's horrible that it happened at all but your response. I mean, I think it was very commendable of the ICU leadership to look at the trend and say you know this is not a normal level of care and this is not a level of care that is equal to normal care that this contingency care of splitting a age circuit three ways over 24 hours is significantly impacting patient outcomes and we need to take steps to address this I think I give them a lot of credit I give the ICU leadership in particular a lot of credit for recognizing that. And I guess the last question is were there any was there any equity monitoring about this policy. Yeah, so we what we've been doing is logging. So in this case there were only 26 patients so there was not as a significant number of patients we were we looked through those cases individually on a patient by patient basis. What we've been doing subsequently with our so we have a conscientious practice policy, which is a long term policy for addressing potentially inappropriate requests for care. And what we're doing is in that policy, we are tracking in a systematic way, every time that policy is implemented the outcomes that policy, and then looking back retrospectively and so we're in the process of monitoring that data and we specifically do intend to examine for equity by race ethnicity socio economic status insurance status and other demographic characteristics and social determinants of health. Oh, see Jesus here we go.