The worst trauma cases in the 65,000-square-mile area around VMC end up in this 31-bed unit. If you are one of those cases, you wouldn’t want it any other way.

by John Howser

LifeFlight lightly touches down onto the rooftop skyport of Vanderbilt University Hospital with a 59-year-old Kentucky man who was badly injured in an automobile crash.

At this moment, this man’s spinal fractures, collapsed lung, multiple rib fractures, severe scalp laceration and hip fracture are the center of the world for the team of trauma professionals treating him. He is the most important person in the world to them.

But in another way, his case is routine, another one of LifeFlight’s more than 3,000 annual transports from within Vanderbilt’s Level 1 Trauma Center’s 65,000-square-mile catchment area.

In the Emergency Department another team of professionals assesses his injuries and starts basic treatment. After that, he is transported to the hospital’s 10th floor to spend several weeks in treatment in the Trauma Center.

His injuries are devastating, a defining event in his life and the life of his family, but to those not involved in the treatment of these extreme injuries, it can be hard to fathom how many trauma patients survive such terrible injuries. Yet, 10 years on, all of this seems routine for Vanderbilt’s Trauma Center veterans.

A decade of difference

Vanderbilt’s Trauma Center opened with public fanfare on Aug. 13, 1998, and a decade later remains the centerpiece of Middle Tennessee’s trauma system. The bricks and mortar physical space of the 31-bed unit may be largely unchanged since ‘98, but the people who work there have done anything but let time stand still.

Since its opeing, the Trauma Center’s admissions have nearly doubled from just over 2,000 per year to almost 4,000. “This increase in the volume of patients is due to the growth in our referral community, and because we’ve lowered our length of stay,” said John A. Morris Jr., M.D., director of Vanderbilt’s Division of Trauma and Surgical Critical Care. “Due to efficiencies we’ve increased patients by a factor of two, while the increase in hospital days has increased only by a factor of 1.7.”

More than 18,000 motor vehicle accident victims, more than 3,600 gunshot victims, 1,500 stabbing victims, 4,000 fall victims, and a significant volume of other injuries from categories such as farm implements, industrial accidents, pedestrians hit by cars and injuries caused by animals have passed through the unit’s doors.

If a patient can survive his or her injuries long enough to make it through the doors of the Trauma Center they have a 92 percent chance of survival.

Morris is a pioneer in the field of trauma medicine, which he says, “wasn’t even a specialty at the time I started.” He was recruited to Vanderbilt in 1984 by former associate vice chancellor for Health Affairs Joseph C. Ross, M.D., and has been VUMC’s Trauma director since. At the time of his arrival Vanderbilt wasn’t readily able to systematically care for large numbers of critically injured trauma victims.

In addition to his responsibilities as administrator, clinician and researcher, Morris is a strategist whose approach to the care and delivery of trauma medicine has helped lead to the integrated trauma system in place at VUMC today. This system includes LifeFlight with its components of rotor-wing, fixed wing and ground transportation, Flight Communications, The Trauma Center and Vanderbilt’s Regional Burn Center.

“The Trauma Center has its origins in the fundamental concept that if you aggregate patients into the hands of a small number of professionals who only deal with that disease process they will learn over time how to deal with it better. Quite honestly, there are things about trauma patients that make them very different from other patients in the hospital,” Morris said. “You can call those differences problems, you can call them challenges, you can call them whatever you want to call them. But trauma patients and their families require unique care.”

Out of this requirement for unique care came the administrative momentum to physically aggregate Vanderbilt’s growing volume of trauma patients into one location, which led to the birth of the 10 North Trauma Center.

“By having a facility to put these patients where there is knowledge, expertise and protocols in place to handle their problems, it’s no longer a problem,” he said. “Trauma becomes a disease like any other.”

The disease of trauma

What is different about the disease of trauma other than the nature of the injuries? Well, the disease happens 24 hours a day, seven days a week. In fact, late night between 11 p.m. and 2 a.m. is the peak time for admissions to the Trauma Center. Many patients who are victims of violence come attached with security requirements. A percentage of trauma patients’ injuries are self-inflicted. Those with traumatic brain injuries require specific protocols as
they begin to regain awareness and exhibit behavioral problems.

“The aggregation of these patients allows us improve clinical care, and to do that in a scientific fashion. This is part of the mission of the enterprise,” Morris said.

Not only is clinical care improved by the aggregation of trauma patients, but by treating all these patients in one place also significantly reduces cost. “What we have seen is that creating these efficiencies, which includes lots of little efficiencies, if you aggregate them our length of stay is about 30 percent less now, and therefore we have lowered cost by 30 percent,” he said.

This increase in efficiency has so far allowed Vanderbilt to continue to treat a growing population of uninsured or underinsured patients. “Under different circumstances this patient population might have led to a reduction or the demise of our trauma program,” he said.

While systems and process for treating VUMC’s trauma patients may be routine by now, many of the patients’ injuries, and how they sustain them, are anything but ordinary. Things that happen to trauma patients—Morris does not call these accidents—are myriad, and frequently hard to believe. The Trauma Center has a history of treating a broadly diverse patient population from all walks of life.

Among the more visible patients in recent years: a rock musician seriously injured in a motorcycle accident; a major country music star and a professional football player, who were both critically injured in auto accidents; members of Middle Tennessee’s law enforcement community injured in the line of duty; a real estate mogul whose personal airplane went down in a cornfield; a rodeo cowboy gored by a bull; a teenager who nearly had his head severed from his body as he was garroted by a wire fence while riding an all-terrain vehicle; an elderly man who suffered a traumatic brain injury after falling from a horse and then having the horse, in turn, fall on his head, and a teenager who had both feet severed by an amusement park ride.

“What I find most gratifying is that the Trauma Center has helped change the culture of the institution as far as going out into the community. The Trauma program has expanded the institution’s reach, and helped change the culture of the institution away from being known only as a quaternary referral center,” Morris said. “We’re much more about meeting the community’s public health needs than we were years ago. The Trauma service, the Emergency Department and LifeFlight have been fundamental catalysts in initiating this change.”

Memories of Jordan

For most health care workers, treating patients who suffer such violent injures may be a once in a year, or even once in a career experience. But after a decade with the Trauma Center there is a core group of highly experienced professionals who relish the daily task of bringing these patients back from the brink. As Morris says, the location of 10 North may comprise the bricks and mortar, but the team of 16 physicians, 108 nurses and 42 staff make up the Trauma Center’s heart and soul.

With their all-black scrubs and T-shirts which say “The Good Guys Wear Black” the staff of the Trauma Center is a breed apart. In ways that challenges and frequent stress can drive people apart, it can also bring them closer together. The veterans of the Trauma Center are a deeply committed group.

Shannon Godby, R.N., CCRN, has been taking care of trauma patients since 1995. She was there the day the Trauma Center opened in 1998 and is now a charge nurse with the unit.

“It’s been really nice to have our own space,” she said. “We’ve outgrown it now, but because of this space we’ve been able to do better for the public, to be able to take care of more patients, and take care of them better with the technology and resources.”

“This can be a hard place to work for some people. We have a high turnover rate for staff, even though we have a lot of people who have stayed a long time. It’s a hard balance to maintain because of what can be an overwhelming volume of patients. But we’ve been good about finding that balance. I’ve stayed because of the teamwork, the camaraderie, the way we work together. We’re a family and that’s what keeps me here.”

Godby notes the care of trauma patients has changed significantly over the decade. “The way we take care of patients has gone with the technology and gone with the statistics. We’ve changed a lot of our practices based upon those things we have found in the past about what works and what doesn’t,” she said.

Among the tens of thousands of patients treated, the Trauma Unit staff has patients from over the past decade who stand out. For Godby the one that stands out is a young man named Jordan, a 17-year-old who was critically injured in a car wreck with some friends.

“He wound up being here for about six weeks. His family and I bonded. Jordan was the same age as my son and his mother and I are the same age,” she said. “It was a long struggle with lots of ups and downs, but Jordan died. I am still in contact with his family and will forever be connected with them. He will forever stand out. ”

Jordan was dying. But Godby and the staff was able to help the family by performing dialysis and by reducing some of Jordan’s medications so that his mind was clearer and he was able to communicate with his family during his last week. “His family, even to this day, has thanked us for giving them a little bit more time to be with him, interact with him, and say goodbye,” she said.

“God Bless the Trauma Nurses”

Melissa Eudailey, R.N., CCRN, an interim assistant manager, actually started her nursing career at VUMC the day the Trauma Center opened in 1998. Hired as a new graduate from nursing school, she was there in her brand new black scrubs the first night the Trauma Center was opened.

“It was very intense because it seemed like there were hundreds of us in black scrubs working that night,” she said. “All of the staff who came from 9 North or the SICU were intensively taking care of our patients, while the rest of us new staff were walking around open-mouthed and not really knowing what was going on,” Eudailey said. “As new graduates or new staff I don’t think we realized how difficult it was for those people who had already been here and were experienced to take on a new unit. It was a steep learning curve and a tumultuous time. But I wouldn‘t change a thing. I‘ll probably be here forever.”

Eudailey’s most memorable patient is Barry, a patient on the Trauma Unit during the very first year.

“He had terrible injuries. He was a grade-five liver laceration, which is usually carries a near 100 percent mortality rate. He was in a car wreck. We did everything we could for him, basically just trying to keep him alive until his family could get here. We had drips going and everything. It was so hot and sweaty, and everyone was working as a team. It kind of gives me chills just thinking about it now.

“We pulled that man back from death,” she said. “It was unbelievable. And he’s now back to work. He’s a vibrant, contributing member of society. He has a wife and five children. Every year now he comes back with a different T-shirt with sayings like, ’God Bless the Trauma Unit,’ ‘God Bless the Trauma Nurses,’ or ‘I Wouldn‘t be Here Without Vanderbilt.’ He’s a big proponent of what we do here.

“This is the hottest, hardest work I have ever done. This is the hardest, most intense, most mentally draining, most physically draining job and I wouldn’t change a minute of it. There is nothing in the world like the adrenaline rush when someone comes back, who turns the corner. There is just nothing like it.”

Like a family

Assistant manager Jamie Wiggs, R.N., B.S.N., is another 10-year veteran of the Trauma Center. “Working here means teamwork, cohesion, and pride in the job we’re doing,” she said. “It is nice to go home in the afternoon and know that you’ve done everything you can for your patient and for their family.”

Wiggs says that staff of the Trauma Center can’t continue to do the job without some levity from time to time. “You can’t do this job day in and day out and not have fun with the people who you work with because with all the tragedy that goes on if you don’t like who you’re working with, and if you can’t cut up and joke around to some extent, you can’t make it from one day to the next,” she said. “This job is hard to do on a good day, but near impossible on a bad day. But it’s a great place to work and I feel blessed.”

Wiggs recalls caring for an Amish man who suffered a very serious facial laceration from a saw blade. “These folks had never been to a big hospital. They were just blown away by everything. But they’ve actually come back to visit us several times to show us how he’s doing and to thank us,” she said.

Wiggs remains close to Kaitlyn Lasitter and her parents. Lasitter is one of VUMC’s more famous trauma patients in recent years. She is the teenager who had both feet severed in a tragic Kentucky theme park accident in 2007. VUMC surgeons were able to successfully reattach one of Kaitlyn’s feet.

“She came back to visit the unit a couple of months ago. No one could believe how well she is doing,” she said. “She walked onto the unit, took a spin, and no one could believe it.”

Unit clerk Joyce Stallworth is another 10-year veteran who gets particular satisfaction when patients recover and return to visit.

“It doesn’t seem like 10 years. It’s been great. I’ve enjoyed every minute of it. I enjoy getting to know the families and watching the patients come back made up and looking like new,” she said. “There have been a lot of sad moments from the ones who didn’t make it, but the ones who come back to visit make up for it. It’s like a family up here. I look forward to coming to work every morning.”

Sarah Hutchison, B.S.N., C.C.R.N., is the unit’s manager. She has been in this role since four months after the unit opened in 1998. Managing 108 nurses and 42 staff members on one of the hospital’s busiest units is a huge responsibility.

“It’s challenging. It’s exciting. I’ve been able to see a lot of miracle cases at the same time I’m continuing to work on system problems because we outgrew the unit’s physical space at a very early stage. This issue and issues with family support have been my biggest concerns,” she said. “But it’s been very fulfilling.”

Hutchison says that nearly doubling patient volume within the same physical space has stressed the system, but the staff has risen to the challenge.

“That’s where we pride ourselves, because with Dr. Morris’ leadership we’ve come up with a great way to efficiently care for more patients,” she said. “Overall, I think we have done a good job and I think the patients’ survival outcomes and feedback from patients’ families have shown this.”


	A House Organ Special Report: Ten Years of Trauma The worst trauma cases in the 65,000-square-mile area around VMC end up in this 31-bed unit. If you are one of those cases, you wouldn’t want it any other way. by John Howser LifeFlight lightly touches down onto the rooftop skyport of Vanderbilt University Hospital with a 59-year-old Kentucky man who was badly injured in an automobile crash. At this moment, this man’s spinal fractures, collapsed lung, multiple rib fractures, severe scalp laceration and hip fracture are the center of the world for the team of trauma professionals treating him. He is the most important person in the world to them. But in another way, his case is routine, another one of LifeFlight’s more than 3,000 annual transports from within Vanderbilt’s Level 1 Trauma Center’s 65,000-square-mile catchment area. In the Emergency Department another team of professionals assesses his injuries and starts basic treatment. After that, he is transported to the hospital’s 10th floor to spend several weeks in treatment in the Trauma Center. His injuries are devastating, a defining event in his life and the life of his family, but to those not involved in the treatment of these extreme injuries, it can be hard to fathom how many trauma patients survive such terrible injuries. Yet, 10 years on, all of this seems routine for Vanderbilt’s Trauma Center veterans. A decade of difference Vanderbilt’s Trauma Center opened with public fanfare on Aug. 13, 1998, and a decade later remains the centerpiece of Middle Tennessee’s trauma system. The bricks and mortar physical space of the 31-bed unit may be largely unchanged since ‘98, but the people who work there have done anything but let time stand still. Since its opeing, the Trauma Center’s admissions have nearly doubled from just over 2,000 per year to almost 4,000. “This increase in the volume of patients is due to the growth in our referral community, and because we’ve lowered our length of stay,” said John A. Morris Jr., M.D., director of Vanderbilt’s Division of Trauma and Surgical Critical Care. “Due to efficiencies we’ve increased patients by a factor of two, while the increase in hospital days has increased only by a factor of 1.7.” More than 18,000 motor vehicle accident victims, more than 3,600 gunshot victims, 1,500 stabbing victims, 4,000 fall victims, and a significant volume of other injuries from categories such as farm implements, industrial accidents, pedestrians hit by cars and injuries caused by animals have passed through the unit’s doors. If a patient can survive his or her injuries long enough to make it through the doors of the Trauma Center they have a 92 percent chance of survival. Morris is a pioneer in the field of trauma medicine, which he says, “wasn’t even a specialty at the time I started.” He was recruited to Vanderbilt in 1984 by former associate vice chancellor for Health Affairs Joseph C. Ross, M.D., and has been VUMC’s Trauma director since. At the time of his arrival Vanderbilt wasn’t readily able to systematically care for large numbers of critically injured trauma victims. In addition to his responsibilities as administrator, clinician and researcher, Morris is a strategist whose approach to the care and delivery of trauma medicine has helped lead to the integrated trauma system in place at VUMC today. This system includes LifeFlight with its components of rotor-wing, fixed wing and ground transportation, Flight Communications, The Trauma Center and Vanderbilt’s Regional Burn Center. “The Trauma Center has its origins in the fundamental concept that if you aggregate patients into the hands of a small number of professionals who only deal with that disease process they will learn over time how to deal with it better. Quite honestly, there are things about trauma patients that make them very different from other patients in the hospital,” Morris said. “You can call those differences problems, you can call them challenges, you can call them whatever you want to call them. But trauma patients and their families require unique care.” Out of this requirement for unique care came the administrative momentum to physically aggregate Vanderbilt’s growing volume of trauma patients into one location, which led to the birth of the 10 North Trauma Center. “By having a facility to put these patients where there is knowledge, expertise and protocols in place to handle their problems, it’s no longer a problem,” he said. “Trauma becomes a disease like any other.” The disease of trauma What is different about the disease of trauma other than the nature of the injuries? Well, the disease happens 24 hours a day, seven days a week. In fact, late night between 11 p.m. and 2 a.m. is the peak time for admissions to the Trauma Center. Many patients who are victims of violence come attached with security requirements. A percentage of trauma patients’ injuries are self-inflicted. Those with traumatic brain injuries require specific protocols as they begin to regain awareness and exhibit behavioral problems. “The aggregation of these patients allows us improve clinical care, and to do that in a scientific fashion. This is part of the mission of the enterprise,” Morris said. Not only is clinical care improved by the aggregation of trauma patients, but by treating all these patients in one place also significantly reduces cost. “What we have seen is that creating these efficiencies, which includes lots of little efficiencies, if you aggregate them our length of stay is about 30 percent less now, and therefore we have lowered cost by 30 percent,” he said. This increase in efficiency has so far allowed Vanderbilt to continue to treat a growing population of uninsured or underinsured patients. “Under different circumstances this patient population might have led to a reduction or the demise of our trauma program,” he said. While systems and process for treating VUMC’s trauma patients may be routine by now, many of the patients’ injuries, and how they sustain them, are anything but ordinary. Things that happen to trauma patients—Morris does not call these accidents—are myriad, and frequently hard to believe. The Trauma Center has a history of treating a broadly diverse patient population from all walks of life. Among the more visible patients in recent years: a rock musician seriously injured in a motorcycle accident; a major country music star and a professional football player, who were both critically injured in auto accidents; members of Middle Tennessee’s law enforcement community injured in the line of duty; a real estate mogul whose personal airplane went down in a cornfield; a rodeo cowboy gored by a bull; a teenager who nearly had his head severed from his body as he was garroted by a wire fence while riding an all-terrain vehicle; an elderly man who suffered a traumatic brain injury after falling from a horse and then having the horse, in turn, fall on his head, and a teenager who had both feet severed by an amusement park ride. “What I find most gratifying is that the Trauma Center has helped change the culture of the institution as far as going out into the community. The Trauma program has expanded the institution’s reach, and helped change the culture of the institution away from being known only as a quaternary referral center,” Morris said. “We’re much more about meeting the community’s public health needs than we were years ago. The Trauma service, the Emergency Department and LifeFlight have been fundamental catalysts in initiating this change.” Memories of Jordan For most health care workers, treating patients who suffer such violent injures may be a once in a year, or even once in a career experience. But after a decade with the Trauma Center there is a core group of highly experienced professionals who relish the daily task of bringing these patients back from the brink. As Morris says, the location of 10 North may comprise the bricks and mortar, but the team of 16 physicians, 108 nurses and 42 staff make up the Trauma Center’s heart and soul. With their all-black scrubs and T-shirts which say “The Good Guys Wear Black” the staff of the Trauma Center is a breed apart. In ways that challenges and frequent stress can drive people apart, it can also bring them closer together. The veterans of the Trauma Center are a deeply committed group. Shannon Godby, R.N., CCRN, has been taking care of trauma patients since 1995. She was there the day the Trauma Center opened in 1998 and is now a charge nurse with the unit. “It’s been really nice to have our own space,” she said. “We’ve outgrown it now, but because of this space we’ve been able to do better for the public, to be able to take care of more patients, and take care of them better with the technology and resources.” “This can be a hard place to work for some people. We have a high turnover rate for staff, even though we have a lot of people who have stayed a long time. It’s a hard balance to maintain because of what can be an overwhelming volume of patients. But we’ve been good about finding that balance. I’ve stayed because of the teamwork, the camaraderie, the way we work together. We’re a family and that’s what keeps me here.” Godby notes the care of trauma patients has changed significantly over the decade. “The way we take care of patients has gone with the technology and gone with the statistics. We’ve changed a lot of our practices based upon those things we have found in the past about what works and what doesn’t,” she said. Among the tens of thousands of patients treated, the Trauma Unit staff has patients from over the past decade who stand out. For Godby the one that stands out is a young man named Jordan, a 17-year-old who was critically injured in a car wreck with some friends. “He wound up being here for about six weeks. His family and I bonded. Jordan was the same age as my son and his mother and I are the same age,” she said. “It was a long struggle with lots of ups and downs, but Jordan died. I am still in contact with his family and will forever be connected with them. He will forever stand out. ” Jordan was dying. But Godby and the staff was able to help the family by performing dialysis and by reducing some of Jordan’s medications so that his mind was clearer and he was able to communicate with his family during his last week. “His family, even to this day, has thanked us for giving them a little bit more time to be with him, interact with him, and say goodbye,” she said. “God Bless the Trauma Nurses” Melissa Eudailey, R.N., CCRN, an interim assistant manager, actually started her nursing career at VUMC the day the Trauma Center opened in 1998. Hired as a new graduate from nursing school, she was there in her brand new black scrubs the first night the Trauma Center was opened. “It was very intense because it seemed like there were hundreds of us in black scrubs working that night,” she said. “All of the staff who came from 9 North or the SICU were intensively taking care of our patients, while the rest of us new staff were walking around open-mouthed and not really knowing what was going on,” Eudailey said. “As new graduates or new staff I don’t think we realized how difficult it was for those people who had already been here and were experienced to take on a new unit. It was a steep learning curve and a tumultuous time. But I wouldn‘t change a thing. I‘ll probably be here forever.” Eudailey’s most memorable patient is Barry, a patient on the Trauma Unit during the very first year. “He had terrible injuries. He was a grade-five liver laceration, which is usually carries a near 100 percent mortality rate. He was in a car wreck. We did everything we could for him, basically just trying to keep him alive until his family could get here. We had drips going and everything. It was so hot and sweaty, and everyone was working as a team. It kind of gives me chills just thinking about it now. “We pulled that man back from death,” she said. “It was unbelievable. And he’s now back to work. He’s a vibrant, contributing member of society. He has a wife and five children. Every year now he comes back with a different T-shirt with sayings like, ’God Bless the Trauma Unit,’ ‘God Bless the Trauma Nurses,’ or ‘I Wouldn‘t be Here Without Vanderbilt.’ He’s a big proponent of what we do here. “This is the hottest, hardest work I have ever done. This is the hardest, most intense, most mentally draining, most physically draining job and I wouldn’t change a minute of it. There is nothing in the world like the adrenaline rush when someone comes back, who turns the corner. There is just nothing like it.” Like a family Assistant manager Jamie Wiggs, R.N., B.S.N., is another 10-year veteran of the Trauma Center. “Working here means teamwork, cohesion, and pride in the job we’re doing,” she said. “It is nice to go home in the afternoon and know that you’ve done everything you can for your patient and for their family.” Wiggs says that staff of the Trauma Center can’t continue to do the job without some levity from time to time. “You can’t do this job day in and day out and not have fun with the people who you work with because with all the tragedy that goes on if you don’t like who you’re working with, and if you can’t cut up and joke around to some extent, you can’t make it from one day to the next,” she said. “This job is hard to do on a good day, but near impossible on a bad day. But it’s a great place to work and I feel blessed.” Wiggs recalls caring for an Amish man who suffered a very serious facial laceration from a saw blade. “These folks had never been to a big hospital. They were just blown away by everything. But they’ve actually come back to visit us several times to show us how he’s doing and to thank us,” she said. Wiggs remains close to Kaitlyn Lasitter and her parents. Lasitter is one of VUMC’s more famous trauma patients in recent years. She is the teenager who had both feet severed in a tragic Kentucky theme park accident in 2007. VUMC surgeons were able to successfully reattach one of Kaitlyn’s feet. “She came back to visit the unit a couple of months ago. No one could believe how well she is doing,” she said. “She walked onto the unit, took a spin, and no one could believe it.” Unit clerk Joyce Stallworth is another 10-year veteran who gets particular satisfaction when patients recover and return to visit. “It doesn’t seem like 10 years. It’s been great. I’ve enjoyed every minute of it. I enjoy getting to know the families and watching the patients come back made up and looking like new,” she said. “There have been a lot of sad moments from the ones who didn’t make it, but the ones who come back to visit make up for it. It’s like a family up here. I look forward to coming to work every morning.” Sarah Hutchison, B.S.N., C.C.R.N., is the unit’s manager. She has been in this role since four months after the unit opened in 1998. Managing 108 nurses and 42 staff members on one of the hospital’s busiest units is a huge responsibility. “It’s challenging. It’s exciting. I’ve been able to see a lot of miracle cases at the same time I’m continuing to work on system problems because we outgrew the unit’s physical space at a very early stage. This issue and issues with family support have been my biggest concerns,” she said. “But it’s been very fulfilling.” Hutchison says that nearly doubling patient volume within the same physical space has stressed the system, but the staff has risen to the challenge. “That’s where we pride ourselves, because with Dr. Morris’ leadership we’ve come up with a great way to efficiently care for more patients,” she said. “Overall, I think we have done a good job and I think the patients’ survival outcomes and feedback from patients’ families have shown this.”