Stefano Mugnaini

Bioethics for the People

In this episode, Stefano Mugnaini shares a success story about how he was able to work with wardens on behalf of incarcerated patients.

Transcript

0:00

Before we start this episode, just want to remind you to protect patient privacy, the details and names in the cases we will be discussing have been changed.Now on to the episode.Welcome to this episode of Bioethics for the People, the most popular podcast on the planet according to Grandma Nancy.

0:20

I'm joined by my Co host Doctor Tyler Gibb, who if he weren't here recording right now, would probably be golfing.And I'm joined by my Co host Doctor Devin Stahl, who dutifully completes the same 5 New York Times puzzles every day.Good morning, Tyler.

0:41

Good morning.All right, so we're kicking off a special series of cases of interviews with clinical ethicists who had some success at their institution, pushing through a policy or a procedure or really crushed a case.Sometimes we just need hopeful, uplifting stories.

0:59

Yeah, the last couple seasons have been a little dark.We're going to be honest.A lot of our work can be tough like that.I'm really excited to highlight some some victories, some successes.All right, so who do we have for today?All right, we've got Stefano from Alabama.

1:16

I I avoided saying your last step because I'm still, I can't, can't say it in my head yet, Munyanini.Munyanini.Munyanini.OK, Stefano, no, I'm not going to try again.I'm going to let, I'm going to let him introduce himself.All right, Stefano, you introduce yourself.OK.

1:32

So I'm Stefano Munyeni.I'm originally from Florida, but I live in Alabama and I'm one of the two primary clinical ethicists at the University of Alabama, Birmingham.My colleague Sybil is next door.And the two of us are pretty much, we work pretty closely with the Ethics Committee and everybody else, but we're, we're the two folks that spend most of our time dealing with specific ethics issues and consults.

1:55

In my experience, it's actually pretty awesome that you have two full time people.So how big is your hospital?I don't know what the most recent numbers are, but we're somewhere in the neighborhood of 1200 beds.Whoa, so you're big?Yeah.And we have a separate hospital that's AI don't know 2 miles down the road.

2:13

It's a was originally a rehab orthopaedics and rehab facility that's been converted to a acute care hospital.And and then we have a big clinic complex that we mostly we step in to help guide decisions about tooth extractions and things like that over there, but but other procedures as well.

2:35

So.Dental clinical ethics, that's an underexplored area for us, I think.Well, so my neighbor's working on a doctorate and she, that is an area that sort of out of the blue she has become deeply interested in.So we're really not sure why, but she's not even sure why.

2:52

But it is something we get a lot of calls because of the, the way this sort of surrogate hierarchy works in Alabama.If someone is truly unrepresented, we can step in and, and consent and make most of their decisions.And there are a lot of folks who come to us from group homes and things like that who need dental work done and don't have anybody who's able to consent.

3:15

So that is a a strangely growing part of our area of responsibility.So.Cool.But today you will have another kind of patient that you want to talk about.So did this start with a case with a particular sort of incident at the hospital that kind of kicked off what you now see as a success story at your hospital?

3:37

Yeah, it it actually, for me, it started as a paper that I wrote for school and it concerned a case that happened at UAB before I was here.And in in defense of my mentor and predecessor, Wendy, Wendy Walters, who is a wonderful person who really brought me on board.

3:57

She wasn't really involved in this case either.This was one of those things where everything sort of went down without ethics involvement, and years later, sort of it became clear what had transpired was not what should have transpired.So I wrote a paper about this case and then found myself reviewing policies related to it and realized that our policy didn't really accord with state law as interpreted by the judges involved.

4:29

That seems like a pretty big oversight.Yeah, I mean, that's so often the case, right, That we we run into a case and we had one a couple of years ago where it was novel case that we'd never seen before and went to the literature.And like the the society statement said, before this happens at your hospital, we recommend that you develop a policy to address this.

4:50

They're like, OK, great, that's not helpful.So, so you had a, so there's a case, historic case, probably one that sticks in the memory of some of the clinicians who were involved in ethics, particularly around incarcerated patients is what you, you had mentioned.And so you did an analysis for school and then came back and and we're able to work on actually changing the policy in order to to help it help that situation.

5:15

Yeah, the first, the first policy here that has my name on it is, you know, related to this case.So that's for me a little bit of a point of pride.I felt like I kind of hit the ground and got something done, so yeah.That's great.Aspirational student work, Yeah.Yeah.

5:31

So walk us through it.What?So tell us about the case and and kind of how you got involved with it.OK, so in 2014, there was a patient who was brought to us from Saint Clair County Corrections Facility, which is in Springville, AL, which is probably an hour, not quite an hour outside of Birmingham.

5:56

And this was a guy who was doing life in prison for a 2007 murder.And somebody in the prison, he and this other individual had had kind of a series of conflicts that eventually ended in Marquette Cummings, who was the the individual in question being stabbed in the eye with a Shank and which, you know, pretty rough situation.

6:26

Obviously it, it sounded like in hindsight, there might have been opportunities to keep these guys separated and it didn't really happen.So he was stabbed in a prison fight or in a fight in prison and was brought to us and very quickly transferred to the neuro ICU.

6:45

He came with a piece of paper that included instructions from the warden that no heroic measures would be taken to save his life, which is a quote.I'm not sure how they defined heroic measures, but, but this was essentially sent with the paperwork from the from the warden and he was made DNR by one of the physicians that evening.

7:10

Somewhere along the way, the patient's the the patient's mother showed up.And here's where the story gets pretty murky.The reporting that I was able to uncover, she either was allowed to visit but not be involved in goals of care conversations, or she possibly wasn't even allowed to visit the bedside.

7:31

The reporting on that varies, but in in either case, decisions were made.The expectation and the understanding of the team was that Mister Cummings was probably had already probably progressed to brain death, but before any of the the neurological testing had begun, on the warden's instructions, they withdrew support and allowed him to expire.

7:58

This, not unexpectedly, perhaps led to a lawsuit.So this paperwork I've did you ever see that piece of paper?Was it in any of the reporting?What did that even look like?That unfortunately I have no idea because this happened in 2014 and I came on board in 2022.

8:18

So my understanding was it was literally just that, you know, we get a, we get a, a packet from the prison Infirmary and the prison medical staff.And my understanding it was just basically a sheet of paper, like like a face sheet or something that had someone had printed on their take no heroic measures.

8:40

And then they were in contact with the warden via phone and it was a phone conversation where they said go ahead and withdraw.OK, so they were consulting it.They didn't just go off this one piece of paper.No, no, OK.There's immediately two big ethics questions that come up.The most glaring is, does the warden have authority to make decisions on behalf of the incarcerated patient?

9:01

And the second is how they allow or how should we allow or inform families about the incarcerated patient being in our hospital.And I, I think I know the answers to those questions that apply for most states.But I mostly get the second question because I think the first has well been settled in our policy.

9:22

But I want to get to how Stefano was able to change his policy to get to it.But there is some gatekeeping that can happen and then there's some gatekeeping that cannot happen.But I typically get the kind of are are we allowed to call the family and tell them, which is a second kind of question.Yeah.

9:38

And part of where this gets complicated in Alabama is there is really broad statutory authority given to wardens to gatekeep communication and visitation.I mean, basically universally they're allowed to say who's allowed to visit, who's not allowed to visit, who we can call, who we can't call.

9:56

Practically, there's a certain amount of, hey, we called the warden to ask if we could call the family, and they haven't gotten back to us.So what can we do?And my tendency is to say, well, until, until they say no, unless there's a really obvious reason why we should be concerned, my inclination is to go ahead and make that contact.

10:23

But most of the time we do try to at least talk to the warden first.One of the things that came out of not our policy change, but this case in particular has been it's made prison wardens much less inclined to want to get into the weeds of these cases.

10:43

And also has, I've found that they have sometimes even in conversations I can just mention, are you familiar with Cummings or Davenport?And they'll say, yeah, So what do you need from us?Oh.That's good.And they're much more willing to work because they recognize that their authority does have a a terminus at some point.

11:05

So tell us about that case.What is?Is that the case that came out of like that legal case?Yeah.So, and I think that that I'll actually say, I think part of the reason that our policy, our, so our policy stated in our informed consent policy for convicted inmates, the warden of the prison is their surrogate decision maker.

11:26

I'm not completely sure how that was part of our policy, but I think it has to do with there were a couple of other cases that sort of unrelated that sort of affirmed that to some extent a warden has some medical decision might they actually said might possibly have some sort of medical decision making authority.

11:48

I think most of the time that's when they're inside the, you know, the prison complex.But, but so because our policy stated that everyone just kind of followed the policy and let the warden call the shots.What I've what I've found now having this in the in the background, they, they are, they are quick to say, we recognize that we're not really in charge here.

12:11

But with this particular case, what ultimately happened was the estate of the family sued and said that they cited a couple of different things.They, they sued on the basis of the prisoner not having been separated from this antagonist, because I think there were two or three separate cases where Mr. Cummings was either in an altercation or was attacked or was harassed by this other individual.

12:40

So they sued on that basis.They said it was essentially cruel and unusual punishment, that there was no isolation and separation.I think that was kind of thrown out.They also sued on the basis of the warden claiming authority for, you know, making end of life medical decisions for the patient without having any express right to claim that authority.

13:04

And so then it all hinged on a question of which this is a timely question, I guess, whether a person acting in that capacity can actually just use their position to claim immunity, qualified immunity in the course of their official duties.

13:23

And that was where the whole case kind of hinged.Yeah.So he was saying, not only did I have the right to do this, I'm protected by the law for having made that decision.You can't come back and sue me.The law protects me in these scenarios.To which the judge said what?It's one of my favorite quotes that came out of actually.

13:42

So there were two decisions in this case because it was heard by the local court and it was heard by the 11th Circuit Court.And there are great quotes in both of the decisions.Not that legal briefs briefs are usually really great reading, but these were.Tyler loves them.Tyler, I know I some of them are really a rollic in good time.

14:02

So so judge by the name of William Pryor, who was the 11th Circuit Court judge.He's actually cited Ashcroft versus Al Kid, which was a Guantanamo Bay case that came out of, you know, in the early days of the ostensible War on Terror.

14:19

They were just rounding random people up and throwing them into Gitmo and then figuring out the charges later.So in this case, Pryor says based on his reading of that breathing room afforded by qualified immunity is generous.

14:35

Although qualified immunity provides government officials with a formidable shield, their entitlement to raise that shield is not automatic.So.All right, so trans translate that for us.Yeah.Well, so basically he said, yeah, you can do almost anything behind the guise of qualified immunity, but you yourself can't determine when qualified immunity is a relevant defense.

15:00

And in this case, the the broader issue was, and I think this had been mentioned by Judge OTT in the lower court ruling, he said, he said the the problem here is when there is a statute that lays out a surrogate hierarchy or anything else.

15:22

And I, I always screw up the Latin here, but there's this legal principle of expressio unius alterius, exclusio or something like that, Exclusio alterius, which means if one thing is included, all other things are excluded.

15:38

I took Latin for four years in high school and I can barely remember 2 phrases.I know I'm killing it.My, my professor, my teacher somewhere is so proud.But basically it's this idea that if, if you include something in a statute, then anything that is excluded, anything that's not included in that statute is necessarily excluded.

16:02

So in this particular case, the state provides a surrogate hierarchy for end of life decision making and it it names a bunch of different people as potential surrogate decision makers specifically at end of life.And anybody not named in that statute then is implicitly excluded from the statute, right and.

16:23

Let me guess, the Warden is not on that list.Turns out they are not.As I mentioned, they do have.There is a another state law that lists very broadly all of the stuff a warden is in charge of.And it does include things like visitation and communication.

16:41

But it does not provide any room whatsoever for a warden calling a hospital and saying, in the popular parlance, hey, go ahead and pull the plug.There's just nothing there for that.Yeah.So, so is that a new state law or do you think your policy?

16:57

So I guess my question about your policy is it sounds like your policy was not in accordance with the state law, right?That your policy was allowing the warden to make decisions even though state law didn't allow the warden to make decisions.Is that right?Yes, but I think it's more that the law had never been really explored in this particular context.

17:21

And so there was an interpretive process and and I mentioned there, there are a couple of other, the most notable one, another case was about a guy who was the acting something or other supervisor at Tutwiler, which is a women's maximum security prison.

17:41

And he's, he was in this acting role for like 18 months and he wanted to get the job permanently.And they, they didn't offer it to him.And they cited the fact that he was a male and they felt like he couldn't do the, the duties of this, this job as a male.

17:57

And one of the things that it hinted at was a warden had some responsibility for the medical needs of inmates.And if it's a warden, he couldn't understand the needs of a female inmate.And that was one of the reasons why he was not chosen for the law.

18:16

And so there's there's this sort of legal nod to the idea that perhaps wardens do have some involvement, appropriate involvement in medical decisions.And I think that was probably what was used to sort of justify this idea.But no one had ever really tested it related to an end of life situation.

18:34

And that's what happened in this case.Stefano that is such a leap though.I mean for this like kind of obscure case, a male female discordance to presume then that the warden can make any and all end of life decision.Seems to me like a hospital lawyer was either like totally in the dark about this policy being written or made quite the like inference from that case, which seems like, come on, I can't be like a popular case in Alabama that everybody knows about.

19:02

So like, dredge it up is like, well, I guess I'm going to make a leap here and say wardens get to make decisions for patients while they're in our hospital, which again, is like a different context because making medical decisions in the Infirmary and making medical decisions in the hospital is also not the same thing.

19:19

Yeah, Yeah.That case is Edwards versus Alabama Department of Corrections from 2000, by the way.And I'm just speculating.I really don't know if that's how it was interpreted, but my guess is that's one of the only cases that was ever involving this idea of wardens and decision making.

19:37

And I suspect that is the the leap that was made.But I agree, I don't think that it was necessarily an appropriate one, but I think you could probably interpret that as to say, well, as long as the decisions in question are not technically end of life, there's at least the defensible aspect to that policy, even if it's not maybe the best idea.

20:00

Seems like a bad idea.OK, Yeah.I agree.I totally agree.Let's give them the benefit of the doubt and say they were trying.There wasn't a lot of directions, so they did the best that they could.But then this case happens and it's very clear that the warden is not supposed to make end of life decisions.

20:16

And then you're this great student who recognizes this.You get hired at the hospital.You look over the policy and go, uh oh, there's a big problem here.So how did you move from like I see a problem newly hired clinical ethicist who wrote a student paper once to actually changing your hospital policy?

20:34

Yeah, and this is where my zeal outstripped my wisdom or my my, my phronesis, as Pellegrino would say, I guess.Yeah.Out kicked your coverage is how we yeah.I just, I just basically started pounding my desk and screaming in ethics meetings, in Ethics Committee meetings.

20:54

I mean, I probably wasn't quite as dramatic as I think I was, but I just said I, you know, we run into these cases constantly and I don't think this is a workable system.We're clearly contrary to the law.So then I also just started, I probably shouldn't say this for something that's going to be out in the world.

21:13

I just started coming up with my own practice trying to figure out how I could navigate these situations.And it, it so happened that the summer when we were working on the policy revision, we had a couple of situations where there were pretty significant aspects to the situation that made it where like the warden's ability to limit visitation was probably a good idea because of some safety concerns, because of the, the violent nature of some of the, the crimes for which these people were incarcerated and concerned that there may be people out there with a, a real desire to get back at them.

21:53

And that actually gave me a really good opportunity to have some long conversations with the warden at, at one of the prisons and kind of work out a process that, although clunky, was at least workable, which is essentially, we contact the warden anytime we get a patient in this kind of situation, you know, possible end of life imprisoned.

22:15

We have them automatically get ethics involved.We make contact with the warden and we basically say, you know, we've got to talk to family to get the right person acting as surrogate.How do you propose we do that?Do you want to be the first contact or do you want us to be the first contact?

22:32

And most of the time we've gotten very little pushback.And they've said, yeah, let us make contact with them first and then we'll get back in touch with you.And, and so once they've made first contact and we've had some conversations with them about things like visitation, generally speaking, they will allow some limited visitation and most restrictions on communication are, are off the table.

22:55

So somewhere in that process, I was able to come back to the Ethics Committee and say, listen, I've just sort of come up with a, a sort of workable way of, of, of doing this.And I really think we should enshrine that into policy.

23:11

And then they called my bluff and said, great, write the policy and send it to us of.Course they did, of course.Who else wants to write that policy?That's great.So it started with the relationship.I mean, that makes a lot of sense to me is you started talking with the warden because it's easy to kind of pigeon hole somebody as being like a bad actor or like unreasonable if you've never actually tried to have the conversation.

23:32

So you establish this relationship, you sort of set the terms.This is genius by saying, but by giving over some authority, saying you know the context, would you like to be the first to reach out or not?So that and you didn't frame it as a question.You said so that we can find the appropriate decision maker.

23:51

And so by setting the terms that way, there was no ambiguity about who was supposed to be making these decisions.Yeah, that's great.Yeah.And you also, you also set it up.So like the thing that we cared about most, the ethics consultation service or you cared about most is making sure that, that that question was answered right.

24:11

And it didn't become like a, a power struggle about like who's in charge of this patient?And, and you know, are you transferring authority and, and all these other things?I find that that's often the the most important thing that ethics consultants can do is help distill the question into, OK, in this situation, regardless of all the other weird contacts that is going on that we can or can't control, we want to make sure the right person is making the right decision for this person as they die.

24:38

Right.And I think a lot of a lot of people are gonna agree with that as the, the, the problem that we're trying to solve.And here's an example of, you know, a way in which I figured out how to do it.And I think that's really great.Yeah.Tell me about cold calling the, the warden.How'd you get in contact with them 'cause I've cold called a lot of people.

24:56

I cold called presidents at hospitals.I've cold called probate court judges, legislators.I've never cold called a warden.You know, Once Upon a time I worked in sales and I hated cold calling and I wasn't very good at it.But I will say prison wardens are easier to get a hold of than just about anybody else.

25:15

It's remarkable, at least in Alabama.And and I think some of that is there is a certain weight when I get a hold of the person that answers the phone for them and say, hey, I'm one of the ethics consultants at UAB Hospital.We've got a patient here, need to talk to the warden.

25:31

There's not usually a lot of gatekeeping.They're pretty quick to put me through because they recognize that, you know, there's some pretty critical things happening.The other thing I mentioned earlier, a lot of times, I'll invoke this case and most of the, there's a, there's a fascinating website called Prison Legal News that again, surprisingly interesting.

25:54

But most of the wardens that I've encountered have have become aware of this case such that they're very quick to say, yeah, we understand that this is not something we can make decisions about, but we need to, you know, figure out what we're going to do.So I've actually found that they've been much less, I mean, much more accommodating and much less resistant than I probably would have expected.

26:15

I've had a different experience with jails than with prisons, but that is probably a sub.I don't know if that's the subject for now or for another day.What do y'all think?Well, maybe try it out and see.We'll see if it makes it fun, OK?OK, no, tell us.

26:31

So the biggest, the biggest issue with jails is because it's much more of a transient situation, most of their medical staff are outsourced from out of state.So my impression and encounters with them has been that they care very little about what the laws in Alabama actually are.

26:51

And their biggest concern is, I mean, they're, they're not, they don't feel responsible for the patient in the same way that prison medical staff and other staff, all other things being equal, I think they do have a sense of responsibility for the people under their charge.

27:08

And I don't see that same level of a kind of a sense of responsibility from the jail.So we've gotten a lot more pushback from jails saying, no, we we're making all these decisions, we're telling you what to do.And also jails are really quick at end of life to just release somebody.

27:24

And I mean, they they sort of couch it in compassion terms, but I think it's more about not getting saddled with a lot of medical bills.But I don't know if that is maybe too judge mental on my part or not.That's interesting.So I heard a guard once say who was standing like positioned outside of a hospital room, say something to the effect of you can't let him die.

27:47

He has to serve out his term.My goodness.As as if like it like justice demanded to keep this patient alive or to prolong his death because he hadn't quite fulfilled his sentence.Which was just like a mind boggling thing to say, but wouldn't happen with a jailer who is less concerned with that because they presumably aren't in for long sentences.

28:10

Yeah.I mean, that's generally speaking, you're on your way somewhere else if you're in jail.That idea, though, of, you know, we can't let this guy die because he has more, you know, suffering to do before his sentence is up, That bothers me on a theological level more than anything else, I think.

28:29

I love that theological level.Absolutely.Like there's so much wrong with a statement like that.Yeah.Maybe for another episode.Yeah.So I do have a question, Stefano, something I was thinking about when we talk about what a warden can and cannot do, so can in Alabama and I think in a lot of states filter communication.

28:48

And that's actually I've this bit has been explained to me, like you were saying as a safety issue, that if some people in this person's life were to know they were in the hospital that you could get access to them, that might place them at a safety risk or their family at a safety risk.

29:05

And that actually does make sense to me.And so you have to have a relationship with a warden who's not trying to like punish, right in the, in the incarcerated person, right?There could be bad actors in this, but we'll presume that that's not what's going on.But my, my posture toward that has always been that there has to be such an explanation in order for us not to reach out that, that there really has to be a reason.

29:28

They can't just say, oh, I'm not going to call the family for arbitrary reasons.They have to say, they have to very affirmatively say this is a safety risk.They have to be able to explain that, right.And so sometimes we do press a little bit.If they say, no, we can't contact the family or, oh, no, I'm not going to do it.Say, well, we're happy to do it unless you think there's a, you know, unless you can give us a compelling reason not to.

29:49

What do you?Think about is that just to jump in?Do you think that's any different than the criteria we use in order to limit anybody's visitation to any of the patients, though there's something unique about being incarcerated that changes that?

30:05

Yeah.Stefano, what do you think?Well, so yeah, I, I think that the same basic premises there that there are situations where it isn't necessarily safe to have someone coming into the hospital.I think the only difference or distinction is in one case you do have a legal statement that a warden has this particular authority.

30:28

Whereas if it's, you know, the hospital having to make that decision, it's it's our own sort of policy that suggests that we have that authority.An additional wrinkle to this, they just passed a law in Alabama fairly recently that allows someone to designate a an essential caregiver who basically, without really strong reasons, is not allowed to be asked to leave the room at any time.

30:59

And this was some response to baggage from COVID when there were times when people really probably should have been allowed to have somebody in the room with them, especially if that person was willing to bear the risk of being in that room and they were excluded.So they wrote this law that basically says, you know, you can designate an essential caregiver, you can designate up to four and they can alternate.

31:19

And one of them has a right to be with you at all times with the exception of a sterile procedure or, you know, something where you're, you can't have somebody in the room or if there are behavioral dangers that arise.So there's like that additional layer kind of legal pressure to, to allow access.

31:39

But I think that really the distinction is just that a warden is named.But I tend to view that as a sort of a negative right, in that until they tell us no, the assumption is like any other patient, we can reach out to family for, for good or for I'll.

31:56

That's the way that I tend to interpret that authority.Yeah, that I think that makes a lot of sense.Yeah.So what one other question as we kind of wrap up this, this case, what is the rate or your experience with incarcerated patients having completed advanced directive paperwork?

32:15

Very, very limited.I don't have a specific number on that.Anecdotally, I've been here two years and we average about 5 to 600 consults a year.A lot of those are very quick.Hey, who's the surrogate phone calls?

32:32

They're not super involved, but so I don't know.I've probably been involved in close to 1000 situations and I can only think of one case where an inmate had an advance directive when he arrived.Now there have been some who have filled them out here, but I don't think it's very high.

32:50

Yeah.I, I don't, I, I guess when, as I think about that question, like I don't think I've ever read anything about those rates or statistics or outreach into that population for that point.But maybe I'm just ignorant on the literature.It'd be a great like in processing thing to do though, right?

33:05

If anything were to happen, what would you want?We do, we do have a, an intervention here where part of the nursing intake is asking some of those questions and it, it gives an opportunity to flag a chaplain to come and fill out an advance directive with a patient, which is AI think a really good thing.

33:24

Unfortunately, what we wind up with in a lot of cases is someone, even if they initially express interest, a lot of times when someone comes to actually fill the AD out, they're like, Nope, no interest in doing that, not going to talk about it or they have lost capacity.And then either case it becomes a a a moot point.

33:40

Well, Stephanie, would you say that this policy that you wrote, I mean, you were kind of already doing it, but you wrote it into policy it, it sounds like then it's been a huge success, right?So are other people now following your strategy?You think it's been mostly successful?

33:55

You said this, the jailers maybe not quite so much, but what do you think the success rate now is of this policy that you wrote?Well, I think the biggest challenge that we're running into now is education and dissemination of the policy.It's been, it's worked really well.

34:11

When we have done it, we've had multiple situations where we were allowed to get someone's daughter to see them, you know, at end of life and participate in their, in their at least the decision making around, you know, what that death looked like.I can think of multiple cases where we were able to accomplish that.

34:31

And I, I, I feel really good about that.I think it's been very successful.The challenge is an institution our size, it's been very difficult to to get that information out to the people.So we do a monthly didactic for the ICU resident group.

34:50

We do something with the ICU fellows each year as they come on board.We teach a didactic for the nursing residency, which, you know, all new hire nurses that are new grad nurses that are they come on board couple other little situations.

35:07

And we make sure to talk about this in every single, every single group of people that we speak to.And yet still in a lot of cases, we'll eventually get looped in and they're like, well, the warden's just been consenting to everything up until now.But somebody said maybe they're not supposed to.

35:24

So we thought we would call you.And we love those because we're like, sweet.It's an opportunity to educate everybody who happens to be standing in this corner.But I think that's the thing, it's been really successful.But we've, we've not, we've not come up with a comprehensive way to let everybody in the institution know, hey, the policy has changed.

35:44

And you know, we've thought about sending mass emails and things like that.But I don't read any of those.So I find it so.I mean, I mean I read them all and digest them deeply.But you understand the impulse not too.Yeah, Yeah, yeah, right.Exactly.Good.

35:59

Well, good luck on continuing to educate.That's such a big hurdle.You can have the perfect policy, but if no one knows it exists, it's not the perfect policy quite yet.Right, right.Yeah, that's a good point.Good.Well, thanks, Stefano.We appreciate you being here and thanks for telling us about your success story.Yeah.

36:14

Thanks for having me, this is really fun.Thanks for tuning into this episode of Bioethics for the People.We can't do it alone, so a huge shout out to Christopher Wright for creating our theme music and to Darian Golden Stall for designing our logo and all of the artwork.

36:32

If you're into what we're doing, give us a rating on Apple Podcasts, Spotify, Amazon Music, or wherever you listen.And if you're really into what we're doing, head over to bioethicsforthepeople.com to snag some merch.It's it's statutorily can't talk.

36:55

You might edit that out.It is.Statutorily granted to the Warden.