Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

The Gatekeepers of “Fairness”


Excellent clinicians spend time listening to patients, acknowledging concerns, and empathizing with feelings that life is not fair.

Pre-rounding with senior residents and nurses is vital to ensure each day in the intensive care unit is well organized. The discussion of pathology is often front-and-center: the complexity of an illness, along with our response utilizing pharmacokinetics, physiology, anatomy, and what further data we need. This focus reshapes objective plans rooted in medicine and science to give the best care possible to our patients.


Planning, protocol implementation, and data review, is often not enough of a response to the human emotions and hard realities that patients and families experience in the ICU. Many families hope against hope that their loved one can soon be defined again by the person he or she was before being admitted to the ICU. For some patients, this may not be a possibility.


Families often ask nurses and physicians, “How is this fair?”


Critical care staff can be seen as gatekeepers of extreme disease management, as well as the gatekeepers of fairness.


The father with newly diagnosed advanced ALS warranting a tracheostomy will live for several more years, but will never have the strength to hold his newborn son.


The woman returning from vacation to a reality of advanced cancer causing multiple organ dysfunction and only days to live.


“How is this fair?”


Intensive care unit providers must communicate to the families that this unfair moment is met with allocation of resources aimed at survival and the best quality of life we can give for their loved one. Listening to and acknowledging the family’s concerns, goals of care, and an understanding of who the patient is and what they would want is of the utmost importance.


We cannot focus on answering, “How is this fair?”


It may not be fair to be perceived as gatekeepers of health’s fairness, for we cannot control the unfairness of organ failure or hemodynamic demise. But we must spend the time listening to and acknowledging the family’s concerns and goals of care for all of our patients.