An external review has concluded that racial bias as well as lack of empathy and compassion were present in the care of Black physician Susan Moore, MD, who died of COVID-19 at an Indiana University (IU) Health hospital in December 2020.
"We owe it to our patients to always show up for them, to treat them with dignity and respect, to appreciate their perspectives, and to validate their feelings when they are in our care. We did not live up to these values with Dr. Moore and acknowledge that we have more to do to become a more diverse, inclusive and anti-racist health system," IU Health CEO Dennis Murphy said in a released on Wednesday.
External Review
After Dr. Moore's death, IU Health conducted an independent external review with a panel of six experts in local and national health. The panel reviewed medical records, interviewed IU Health personnel, and reviewed organizational policies and procedures. The panel concluded that medical management and technical care did not contribute to her death, but that there was "lack of empathy and compassion" in the care she received.
The panel also concluded that not all providers practiced cultural competence, and that several caregivers "lacked empathy, compassion and awareness of implicit racial bias in the delivery and communication" of her care.
Begging for Care
On Nov. 29 2020, Moore was admitted to IU Health North Hospital in Carmel, Indiana, after she tested positive for COVID-19 and had symptoms requiring hospitalization. Soon after being placed in the care of a white physician, she began posting voicing concerns about her care. Included in these concerns was the need to "beg" for remdesivir (Veklury) as well as a chest CT, which she eventually received and showed large mediastinal lymphadenopathy as well as lower lobe pulmonary infiltrates bilaterally.
She said she encountered resistance when she requested pain medication for severe neck pain. After speaking with a patient advocate and the hospital system's chief medical officer, she was assigned to a new pulmonologist and received a new care plan. After receiving an increased dose of dexamethasone, she appeared to improve and was discharged home. Just 12 hours later, however, she was re-admitted with worsened symptoms to another hospital, Ascension St. Vincent in Carmel, Indiana.
"Everyone has to agree they discharged me way too soon," Moore posted on Facebook, regarding IU Health North Hospital.
"This is how Black people get killed, when you send them home, and they don't know how to fight for themselves," she said in the video.
Her final update said she was on bilevel positive airway pressure (BiPAP) and was being transferred to the ICU, where she then died on Dec. 20, at age 52.
Next Steps
IU Health said it is responding to the external review's recommendations by developing a timeline and accountability structure to improve delivery of compassionate and evidence-based care in their system, as well as improving cultural competency and awareness of racial bias among IU Health employees.
Among a number of next steps that IU Health says it will be taking include training in compassion, empathy, and cultural competency for employees, hiring more patient care advocates, publicly acknowledging the history of racism in healthcare and Indiana, and establishing a response team trained in addressing racial tensions. IU Health also said it will publicly report data and progress on its website.
"We believe the findings and recommendations of this external review will drive forward a plan of action for IU Health to become a more inclusive, equitable and respectful healthcare system for all," Murphy said in the statement.