513 - Loop Diuretics, Good Grief, You Are “Grief-Worthy”

From the Literature

1)  Loop Diuretics – Better Choices

During the COVID-19 pandemic, admissions for several “ambulatory-care-sensitive” conditions (e.g., congestive heart failure) decreased. As we emerge from the pandemic, we are seeing these rates rise – especially heart failure. Loop diuretics are the principal tool with which to manage exacerbations of congestive heart failure, regardless of systolic function. We were trained on furosemide as our default loop diuretic, but we have seen torsemide and bumetanide being used with apparently better results.

A systematic review was recently conducted comparing furosemide and torsemide use in both chronic and acute-on-chronic heart failure examining overall mortality and hospitalization outcomes. Multiple databases were searched, but there was not a search for unpublished literature. The authors did critically appraise the studies and assessed them for heterogeneity. Ten RCTs (N=4217) were found that met criteria. Quality of the studies was overall moderate – most studies did not adequately blind the intervention or conceal allocation. There was no difference in overall mortality between furosemide and torsemide over the 3-18 months of the studies. There was a reduced incidence of heart failure hospitalization with torsemide (RR 1.65, 95% CI 1.21 to 2.24, I² = 0%, NNT = 12), and the effect was less, but still significant, for all-cause hospitalization and cardiovascular hospitalization.

Prescriber’s Letter (a fee-based pharmaceutical review newsletter) notes the poor oral absorption of furosemide as a limiting factor. It recommends switching to torsemide (possibly bumetanide) for clinically severe heart failure presentations as it has a longer duration of action and more evidence for heart failure. The American College of Cardiology/American Heart Association guidelines for the management of congestive heart failure note the potency differences between furosemide and either torsemide or bumetanide, but do not cite a distinct preference for use.

John’s Comments:

In our era of value-based care, keeping people out of the hospital is important to reduce overall costs of care. For patients with more than mild heart failure or for whom furosemide is not working, torsemide should be considered. For patients presenting with worsening heart failure who can still be cared for as an outpatient, switching to a more potent loop diuretic like torsemide also seems prudent. Furosemide 40 mg is equivalent to 10-20 mg of torsemide or 0.5 to 1 mg of bumetanide.

References:

• Singh S, Goel S, Duhan S, et al. Effect of Furosemide Versus Torsemide on Hospitalizations and Mortality in Patients With Heart Failure: A Meta-Analysis of Randomized Controlled Trials. The American Journal of Cardiology. 2023;206:42-48. Link
• Comparison of Commonly Used Diuretics. Prescriber’s Letter. Published online May 2021. Link
• Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145(18):e895-e1032. Link

From the Family Practice Management Literature (and Mark)

2)  Good Grief:  Healing From Personal and Professional Loss

Grief is the anguish experienced after significant loss, and it often includes physiological distress, separation anxiety, confusion, yearning, obsessive dwelling on the past, and apprehension about the future.² Family physicians experience personal or professional grief almost daily, but we are not always consciously aware of it. 

Grief can manifest in multiple ways:

• Acute grief is defined as tearfulness, sadness, and insomnia as a response to loss, and typically lasts for less than a year;
• Anticipatory grief involves feelings of loss experienced prior to the expected loss;
• Complicated or prolonged grief manifests as intense and persistent grief that causes problems and interferes with daily life;
• Ambiguous grief refers to loss that does not allow for the possibility of closure (many of us experienced this during the pandemic);
• Disenfranchised grief involves a loss that is not openly acknowledged as legiti­mate by society and is often accompanied by feelings of shame, guilt, and further iso­lation (this can be a contributing factor to physician burnout).

Increasingly, physicians’ professional grief may be related to moral distress or injury. Moral distress refers to “when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action.”  Moral injury refers to “distress that occurs when clinicians are repeatedly expected to make choices that transgress their deeply held commitment to healing.

Because of the historical culture of medicine as well as one’s family and culture of origin, physicians and trainees are often unprepared to process their grief and fear being seen as “weak” or “too emotional” if they were to openly discuss their experiences.  Destigmatizing grief and bearing witness to one another’s suffering is important for the sustainability of our work. Doing so can help us validate our experiences, feel less isolated, develop empathy, and move forward without burning out.

Helping Ourselves:  None of us are likely in a position where we can immediately change the system to prevent moral injury, professional grief, and loss. But even in a broken system, or perhaps especially in a broken system, we must take steps to heal ourselves. Here are three ways to begin.

• Self-reflection. Although it sometimes gets dismissed as a “soft skill,” the habit of self-reflection is key to identifying and processing strong emotions so we can move forward effectively.  Consider a framework such as "RAIN" (Recognize, Allow, Investigate, Nurture) to guide the process.
• Self-compassion. Embedded in the above process, self-compassion can help us reframe our thoughts and allows for emotional healing. It entails being warm and understanding toward ourselves when we suffer, fail, or feel inadequate, rather than ignoring our pain or flagellating ourselves with self-criticism. 
• Counseling. This is an important but often underutilized resource that can help clinicians navigate the complexities of loss. If grief is causing physical problems and interfering with your daily life, it may be time to see a professional counselor or your personal physician. 

Helping Each Other:  Once we have begun to care for ourselves, we can begin to assist those around us more effectively. Here are three recommended practices.

• Empathy. Seeking to understand the feelings of others, instead of shaming or judging them for their feelings, can help normalize grief and promote healing. A useful tool for expressing empathy is the NURSE framework (Name, Understand, Respect, Support, Explore).
• Meaning-making activities. Group rituals or activities have long been utilized to process grief and create meaning. Examples include storytelling, artwork or other creative expressions, or annual ceremonies to remember and honor the loss. These activities do not restore the loss but can help one or a group move forward.
• Connection. Another way to normalize grief conversations for your colleagues and care teams is to offer a formalized approach for connection and debriefing, especially for difficult cases.

Mark’s Comments:

With all the opportunities we have, we clinicians should be “grief experts.”  Unfortunately, the culture of medicine as well as often our own family, culture, and even faith of origin have not equipped us to grieve effectively.  To that end, see additional thoughts about disenfranchised grief in our PeerRxMed Pointer for this week. 

Reference:

Owens M and Greenawald M.  Good Grief:  The Art of Healing Ourselves From Personal and Professional Loss.  Fam Pract Manag.  2023; 30(5):25-28.  Link

From PeerRxMed ( www.PeerRxMed.org )

3) You are “Grief-Worthy,” So Don’t “Dis” Your Grief, and Theirs

"Grief is not a disorder, a disease or a sign of weakness. It is an emotional, physical and spiritual necessity, the price you pay for love. The only cure for grief is to grieve."  Rabbi Earl Grollman, author and an internationally recognized bereavement counselor

I used to think I was “bad at grieving.”  Often, what I was feeling on the inside as a result of loss never seemed to quite make it to the “outside,” and when it did, what was expressed didn’t really capture what I was feeling.  Even more often, I preempted what was trying to be expressed by deeming it unworthy of expression.  In doing so, I now understand I was experiencing a common phenomenon for healthcare professionals called self-disenfranchised grief – when we deny, minimize, or trivialize our own grief.

Where did I learn this behavior?  There are many factors that contribute to the grieving experience, including an individual’s personality, their past experiences with grief, other factors in their life, the specific circumstances involved, as well as the values and norms of their family and culture of origin and those of their present culture/s.  In the “culture of medicine” and certainly in medical training, too often the practice of disenfranchised grief is reinforced and even encouraged.   

Disenfranchised grief occurs when the emotional reaction to a loss is not openly accepted as appropriate or justified and can therefore go unacknowledged or unsupported.  It can be reinforced by words and phrases such as “unprofessional,” “too emotionally involved,” or “just get over it.”  Not feeling welcome or comfortable to outwardly express the emotions that come with a loss exacts an emotional toll that can be isolating and long-lasting.  It can also be turned on oneself, causing denial or suppression of grief not only in professional circumstances, but in the entirety of life.  

Where does this commonly show up for we clinicians?  Our medical practice brings us to the “intersection of life,” where loss is commonplace.  Those we care for daily bring their loss to us, from chronic disease and disability in themselves and others to the loss of a job, a loved one, a relationship, material possessions, a pet, or a dream.  We often feel the need to “protect” ourselves from the emotional toll associated with all this loss, and can project that onto others as well.  Soon, we can become “hardened” to it or find unhealthy outlets to “escape” from it, and in the process, lose our compassion, our humanity, our “soul” … and often, our health. 

It is therefore essential for we who work in healthcare to find a better way to advocate for, create, and promote cultures that support healthy grieving for ourselves, our colleagues, our care teams, and the patients and families we serve.  That process starts by acknowledging, rather than disenfranchising, the grief we experience and honoring how we experience it.  While there is no one way to grieve, we grieve “badly” when we suppress, rather than finding constructive ways to express, the emotions we are experiencing around loss.   The good news is that you are surrounded by others who are on a similar journey.  Reach out and check in with them often and allow them to do the same with you.  Remember we are never alone on this professional journey unless we choose to be – and no one should care, or grieve, alone.

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org