The Zentensivist Manifesto. Defining the Art of Critical Care.

Evidence-based medicine asks us to integrate the best available evidence with clinical experience and patient values. In the modern intensive care unit, the primary focus is on complex technology and electronic health records, often away from the bedside. Excess interventionism is the norm. The term "intensivist" itself implies an intensive management strategy, which can lead us away from a patient-centered practice and toward iatrogenic harm. Under the hashtag #zentensivist, an international, multiprofessional group of clinicians has begun to discuss via Twitter how to apply key principles of history taking, physical examination, physiology, pharmacology, and clinical research in a competent, compassionate, and minimalist fashion. The term "zentensivist" intentionally combines concepts seemingly at odds-Zen philosophy and intensive care-to describe a holistic approach to the art of caring for the critically ill. We describe the key tenets of zentensivist practice and how we may inspire these actions in those we lead and educate.

Preface

This commentary describes a minimalist, essentialist (1) approach to the practice of critical care medicine. As a reaction against the interventionism that the term “intensivist” conjures, the parodied term “zentensivist” was created (2). Zen philosophy encapsulates many of these values, described by one teacher as “stripped-down, determined, [and] practice-oriented” (3). The usage of Zen philosophy is not intended as appropriation or espousing any particular religious or spiritual beliefs.

Introduction

Evidence-based medicine calls for integrating the best available evidence, clinical experience, and patient values (4). Such a competent and humane approach is particularly important in the care of critically ill patients and their families. However, in the intensive care unit (ICU), excess interventionism often takes place under the guise of providing evidence-based medicine. Even the term “intensivist,” used to describe the professional role of critical care clinician (5), implies an intensive management strategy, too often associated with iatrogenic harm.

Calls for a cautious clinical practice and a “less-is-more” mindset are not novel in the history of medicine or critical care (6, 7). It has long been recognized that many medical interventions offer only marginal benefit, with many practiced broadly only to be subsequently minimized, if not outright retracted (8). The medical philosopher Jacob Stegenga has advocated for a “gentle medicine” approach, whereby we as a profession realize the shortcomings of our offerings and only intervene carefully and when the upside is clear (9). Major United States critical care societies also acknowledge the need for careful, expert reasoning before integrating available medical knowledge into our daily practices (10). Despite this history, a tendency toward interventionism persists, and a counterbalancing force is needed.

Twitter and other social media platforms have provided an unprecedented forum for dissemination of ideas and case-based discussions, where clinicians across the globe can share their bedside approach to the most challenging problems. The hashtag “#zentensivist” was created and grew organically with an international, multiprofessional group of clinicians discussing how to apply medical physiology and clinical research in a competent, compassionate, and minimally burdensome manner (Figure 1). The term “zentensivist” intentionally combines concepts seemingly at odds—Zen philosophy and intensive care—to describe a holistic approach to the art of caring for the critically ill. In this review, we outline some of the principles developed during these discussions on Twitter and use this framework to describe the key aspects of applying critical care expertise according to patient needs, values, and preferences.

Figure 1.

Word cloud generated from twitter users when asked “What words, phrases, or concepts come to mind when you hear the term #zentensivist, or a #zentensive care unit?” (34).

Abiding Abnormality

Respecting abnormal physiology as an adaptive response is an essential zentensivist practice. Aberegg and O’Brien have cautioned against the “normalization heuristic” (11) that is pervasive in medicine, whereby all patient parameters are driven toward “normal” values. The putative benefit of normality is diminished the further a patient is from homeostasis, as demonstrated by decades of blood transfusion trials in critical care (12, 13).

As a medical community, we understand physiologic adaptations to acute and chronic diseases superficially at best and are unlikely to outsmart the evolutionary forces underlying these adaptations. Whether it be fever (14), hyperglycemia (15), or chronic electrolyte disturbances, the available evidence does not support an interventionist approach to restore “normality.” And in some cases, such as permissive hypercapnia in the acute respiratory distress syndrome, the “abnormality” is plausibly protective (16). Distinguishing adaptive (should be left alone) from maladaptive (needing correction) response to critical illness and injury is challenging, and a conservative approach is prudent to avoid iatrogenic harm.

Pragmatic Practice

Zentensivists do not adhere to a single, unchanging “textbook” construct of human physiology and disease, unaffected by external influence. They disbelieve, on principle, any statement with the formula “all patients with [condition X] must undergo [intervention Y].” In the words of William Osler, “the good physician treats the disease, the great physician treats the patient who has the disease” (17).

Unfortunately, medical training programs tend to reward those who excel at memorization of complex subjects within a rigid, sterile framework. Rare conditions receive special attention. Few training systems promote base rate statistical thinking in a clinical context. In medical practice, those who do “more” and order esoteric tests may receive positive reinforcement from this system. In contrast, Keijzers and colleagues have called for “deliberate clinical inertia,” whereby “doing nothing” is considered a positive response (18). Accordingly, the zentensivist stands back and watches the interaction of external factors with human physiology, indexing the outcome with common sense.

Calming Presence

The chaotic, high-intensity environments where critical care takes place can generate distress for patients and clinicians alike. A zentensivist consistently exudes calm as an active intervention. Fostering this type of atmosphere can promote healing even during times of crisis (19). Whether it be a cardiac arrest resuscitation or an emotional family conference, the zentensivist demeanor brings a soothing presence to the situation.

A zentensivist manner opens the door to bonding with patients and other caregivers, thereby restoring humanity to the ICU (20). It is manifested by honesty, humility, and patient advocacy, effectively allowing the patient and family to be heard. When possible, lighter moments of joy and laughter are fostered. Serenity encourages clarity of thought in the face of clinical deterioration, during complex procedures, and in end-of-life scenarios.

Risk Tolerance

In the ICU, uncertainty introduces desire and pressure to intervene. Consider the common practice of performing exhaustive work-ups; evaluation of every patient for myocardial infarction and pulmonary embolism undermines principles of pretest probability and clinical reasoning. Overdiagnosis of conditions such as ventilator-associated pneumonia leads to unnecessary antibiotics (21), increasing downstream testing and other interventions. Many disease processes are assessed and treated in the interest of “erring on the side of caution” without considering the ramifications of false positives and adverse effects. Indeed, excessive caution can cause harm.

Zentensivists practice parsimony in the use of resources, avoiding “routine” labs and imaging (22) and ordering tests only when there is a clinical question that can be answered by that test. Medications are pared down to a minimum, especially considering that no pharmacologic interventions have meaningfully improved outcomes in multicenter critical care trials (17). Risk tolerance is a defining feature of zentensivism, as risk is a natural part of life. With that in mind, our educational efforts need to normalize uncertainty (23). Given the limited evidence for many interventions in critical care, and the potential for iatrogenic harm, zentensivists are often intentionally passive.

Treading Lightly, but Swiftly

Minimally invasive critical care requires a balance of deliberate inaction paired with rapid yet measured activity in time-critical situations. Overly invasive care has a tendency to beget more invasive care. Zentensivists favor the intervention with less harm and similar effect size, such as a well-placed peripheral line over a sterile central line. Invasiveness for the sake of “convenience” or “just in case” is minimized. Removing or avoiding devices, catheters, and sedation (24) is aggressively pursued whenever possible.

Rapid, targeted action is exemplified in situations such as prompt identification of septic shock and administration of antibiotics (25), expedient source control of infection or bleeding, and other time-sensitive “golden hour” interventions. Vasopressors, perhaps administered peripherally (26), and judicious use of fluids may prevent subsequent organ failures that would require more invasive critical care, such as mechanical ventilation or renal replacement therapy (27).

Avoiding and Alleviating Suffering

The zentensivist framework appropriately concentrates care on the alleviation of suffering, whether the treatment plan has curative intent or not. Though there may be modest improvements in ICU outcomes over time, mortality rates will always be considerable. Proximity to death is the nature of our field. Clinician discomfort with this concept can affect how we make decisions regarding limitations of care, including provision of life support (28). Zentensivists practice “early goal-directed palliation” in cases in which ICU-level care is more likely to result in death or significant impairment (22). We also focus on prompt identification of patient goals of care, preferences, and values (29) so that we may avoid those fates that some may consider worse than death (30).

Essentialism

The modern ICU pairs a deluge of data with extraneous noise, both literal (31) (e.g., alarm fatigue or bloated electronic health records) and figurative (outcome measures set by governing bodies). These factors can distract from the core set of interventions that have the largest impact on patient well-being. Clinicians must have the mental space to attend to lung-protective ventilation and the ABCDEF (Assess, Prevent, and Manage Pain, Both Spontaneous Awakening Trials [SAT] and Spontaneous Breathing Trials [SBT], Choice of Analgesia and Sedation, Delirium: Assess, Prevent, and Manage, Early Mobility and Exercise, and Family Engagement and Empowerment) bundle (32), practices that have large and measurable impact on outcomes important to us and, more importantly, patients. Zentensivists recognize and promote these interventions and avoid those that act as distractions. We emphasize care that limits the harm our patients are exposed to, focusing on liberating them from our environment.

The Way Forward: An Agenda for Education and Research in the Art of Critical Care

How can we create more clinicians and care units with the pragmatic, patient-centered focus described above? Many of the principles discussed require expert clinical reasoning skills, risk tolerance, and understanding of the potential short- and long-term effects of our interventions as well as base rate statistics. Though education on many of these topics may be increasing in undergraduate medical and allied health professional education, it is past time to model them at the bedside. Examples of ideal zentensivist behaviors versus more aggressive “usual care” are shown in the example case in Figure 2. We have the potential to undo reflexive interventionism on the part of those we educate (33), which can be enhanced by normalizing both uncertainty and thoughtful inaction by way of meta-cognition (18, 23).

Figure 2.

Example case showing differences in management when following zentensivist principles (right side of diagram) compared with usual care (left side). Though the likelihood of survival may not differ significantly between the two paths, the invasiveness, humanity, and level of patient comfort may differ greatly. ABCDEF = Assess, Prevent, and Manage Pain, Both Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT), Choice of Analgesia and Sedation, Delirium: Assess, Prevent, and Manage, Early Mobility and Exercise, and Family Engagement and Empowerment; BP = blood pressure; CBC = complete blood count; Cr = creatinine; CT = computed tomography; HFNC = high-flow nasal cannula; HR = heart rate; ICU = intensive care unit; NRB = non-rebreather mask; PIV = peripheral intravenous line; POCUS = point-of-care ultrasound exam; RR = respiratory rate; SpO2 = oxygen saturation by pulse oximetry; TEE = transesophageal echocardiography.

Social media allows clinicians to share and learn the practice patterns of others, creating informal educational and mentoring relationships that can expose them to new ways of thinking about old problems. These conversations allow us to reflect on our own practices and biases and ask, what is the minimally burdensome appropriate care I can provide to help patients recover? How aggressively can I liberate them from our interventions?

Many critical care trials focus on adding or intensifying interventions, especially medications or procedures. Deadoption may be a better design and would also be more inclusive of resource limited settings and low- and middle-income countries. Pragmatic trials that are conducted efficiently will provide evidence of how care might be implemented outside of a research environment. They are also opportunities to explore our current practices in a way that focuses on subtraction of the unnecessary.

We must regain the balance that has been lost in critical care practice. We propose this balance is best achieved through embracing principles that focus our attention on high-impact interventions while minimizing suffering and maximizing humanity. We believe these tenets of zentensivism are essential to instill in future generations of critical care clinicians.