Self care of Physicians Caring for Patients at End of Life

Palliative Care Journal Club

Dr. Judy Littleford MD, FRCPCSeptember 15th, 2009

Self care of Physicians Caring for Patients at End of Life

• Kearney MK, Weininger RB, Vachon MLS, Harrison RL, Mount BM

Corresponding author visiting Professor at Santa Barbara Cottage Hospital & McGill, originally trained in Palliative Care in Ireland (MB BCH BAO FRCPI) ~ 1980-86

First qualified Palliative Specialist in Ireland, Palliative Care Consultant & Medical Director in Dublin until 2003

Has training in psychoanalysis, spiritual healing, dreamwork

Introduced “Healing in Medicine” into the undergraduate medical curriculum at McGill

Modest publication record (4 peer-reviewed articles, 1 book, 4 book chapters)

3 Canadians: Vachon (Toronto), Harrison (Vancouver), Mount (Montreal)

Importance of the topic: Self-care

• Personal reasons Lengthy history of intense investment in

work/study A new career focus provides an opportunity for

self-reflection

• Reasons presented by the authors Essential part of the therapeutic mandate Enables physicians to care for patients in a

sustainable way with greater compassion, sensitivity, effectiveness & empathy

Objectives

• Examine burnout & compassion fatigue Define & discuss contributing factors Review presenting signs & symptoms

• Present evidence for prevention of burnout & compassion fatigue

• Explore the practice of empathy• Offer an approach to maximize physician wellness

through self-awareness in the setting of caring for patients with end-stage illness

• Discuss practical applications of self-care in the workplace

Self care of Physicians Caring for Patients at End of Life

Palliative Care Journal Club

Dr. Judy Littleford MD, FRCPCSeptember 15th, 2009

http://www.statisticssolutions.com/professional-quality-of-life-scale

Literature review

• Literature review presented in article is: Up to date Draws from oncology, palliative medicine,

psychotherapy and trauma literature because of their belief that physicians in these fields face similar challenges & rewards

Provides a good synthesis of ideas Includes web resources

Methods: ethical considerations

• Ethical considerations Financial disclosures: None reported The section of JAMA to which the article was

submitted « Perspectives on Care at the Close of Life » is funded by a grant from the Archstone Foundation

The funding agency played no role in the collection, analysis and interpretation of data, or in the preparation of the manuscript

Burnout

• Environment Clinician• Overwhelming workload, little support,

role conflict, ambiguity, lack of control, loss of autonomy

• Form of mental distress manifested by decreased work performance

• Associated with suboptimal patient care, medical errors, lower patient satisfaction, longer post-discharge recovery

JAMA 2006;296(9):1071-8Health care manage review 2008;33(1):29-39

Burnout signs & symptoms

• Emotional exhaustion - feeling overextended & depleted

• Depersonalization - detachment from the job, negative or callous responses

• Sense of ineffectiveness – feelings of incompetence or underachievement at work

• Cynicism (not part of the 22 item Maslach Burnout Inventory)

Maslach is credited with one of the most widely used definitions; “A syndrome of emotional exhaustion, depersonalization & reduced personal accomplishment that can occur among individuals who do people-work of some kind."

See Table 1, page 1157 for comprehensive list of S & SJ occupational behaviour 1981;2:99-113 (original Maslach burnout questionnaire)http://www.rci.rutgers.edu/~sjacksox/PDF/EvaluatingStress.pdf

Burnout Demographics

• Seen to a greater extent in: Younger caregivers, those with added responsibility of

children or elderly parents, singles Highly motivated health professionals with intense

investment in their profession Those with a self-destructive pattern of overwork &

habitual delay in attending to significant relationships Professionals who postpone self renewal activities

• Previous mental health problems (depression)• Impulsive, intense personality traits

Compassion Fatigue

• Patient Clinician• The “cost of caring” for others• Signs & symptoms:

Hyperarousal (disturbed sleep, angry outbursts, hypervigilance)

Avoidance (desire to avoid thoughts, feelings, conversations about pain & suffering)

Re-experiencing (intrusive thoughts & dreams, distress in response to reminders of work with the dying)

Methods: data collection

• Epidemiology of burnout in oncology & palliative care – Review of the literature

• Topic of interest in 23/112 papers cited 18 published in 2000 or later 2 international studies (UK, Japan) comparing

palliative physicians & oncologists found less stress amongst the former

Postulate palliative physicians work with team support Oncologists begin from the initial premise of hope

Work Environment Stressorsin Palliative Care

• 3 references, same lead author (Vachon) Constant exposure to death Inadequate time with dying patients Growing workload Inadequate coping with one’s own emotional

response to dying patients Identification with or developing friendships

with patients Communication difficulties with

patients/relatives

Rewardsin Palliative care

• Appreciation of the reciprocal healing process which occurs through meaningful caregiver-patient relationships Opportunity for inner self reflection Connection with peers, family & community Heightened sense of spirituality Both biomedical & psychosocial aspects of care

• Rewards less likely if: Physician role is primarily biomedical Job engagement not possible

JAMA 2006;296:1071

Results: Factors Mitigating Burnout

• Having some control over personal schedule & hours worked

• Practising in teams with shared responsibility/leadership for clinical decision-making

• Job engagement Sustainable workload, appropriate recognition.

feelings of choice & control, supportive work community, fairness & justice, meaningful work

• Spirituality• Enhanced self-awareness (Meditation & Reflective writing)

See Table 2 for List of measures that may help prevent burnout

Self Awareness versus Self Care

• Self care, an example of which is maintaining clear professional boundaries, offers protection from occupational stressors

• Self care without self awareness results in a clinician who is less emotionally available & who finds work less rewarding

• Self awareness involves self knowledge & simultaneous attention to the patient, work environment & one’s own subjective experience, in the moment (Reflective)

• Self awareness expands one’s range of choices & allows for more creative responses in any given situation

Results: Factors Mitigating Burnout

Davidson, Kabat-Zinn, Psychosom Med 2003;65: 564-70Neuroreport 2005;16(17):1893J Gen Intern Med 2005;20(7):559

Jon Kabat-Zinn PhDMindfulness-Based Stress Reduction Model (since 1979)Original work to help patients tap their own deepest inner resources for learning, growing, healing, transformationRecent randomized clinical trial showed (+) changes in:• brain activity• immune function• emotional processing under stress

Mindfulness Meditation Practice

• Process of developing careful attention to minute shifts in the body, mind, emotions, environs while holding a kind, non-judgmental attitude toward self and others

• Raises a physician’s consciousness of their inner reality (physical, emotional, cognitive) and of the external reality with which they are interacting

• Helps develop a kind, objective witnessing attitude toward self & empathy for others

Mindfulness Meditation Practice

• Psychological benefits Anxiety reduction Enhanced sense of well-being Alleviation of pain Increased self-compassion & empathy for

others Greater sense of:

Self-actualization Self-responsibility Self-directedness

Train Educ Prof Psychol 2007;1(2):105Int J Stress Manag 2005;12(2):164Am Psychol 2006;61(7):305J Behav Med 1998;21(6):581

Results: Factors Mitigating Compassion Fatigue

• Practice of exquisite empathy• Defined as

“Highly present, sensitively attuned, well-boundaried, heartfelt empathetic engagement”

• Invigorates rather than depletes• Refutes the commonly held notion that

being empathic to dying patients leads to emotional depletion

• Facilitated by self-awareness

No access to cited references

Discussion

• Physician self-care & self-awareness are crucial components of wellness and an essential part of the therapeutic mandate in caring for patients at the end of life

• Formal & informal methods are available• Throughout the article, major findings are

interpreted and discussed in the context of prior research

Suggestions for practicing self-care and self-awareness are listed in Table 3, page 1161

Discussion

• Major strengths of this paper Readability Synthesis of ideas Review of the available literature by seasoned

practitioners in palliative care Offers web-based resources Importance of the subject matter

• No identified weaknesses• Provides « food for thought » applicable at an

administrative level, at a time when the PM division is undergoing rapid expansion & evolution

• Further discussion…