Sustaining Our Ability to Provide Palliative Care

2. Sustaining Our Ability to Provide Palliative Care Palliative Care Update 2009 David F. Giansiracusa, MD Director, Palliative Care Program Maine Medical Center Portland, Maine

3. I have no relevant financial relationships to disclose. David F. Giansiracusa, M.D.

4. Why discuss compassion fatigue, burnout, and self-care at a Palliative Care symposium ?

5. “Physicians (clinicians) working with patients at the end of life frequently have to respond to overwhelming human suffering….Self care is an essential part of the therapeutic mandate. Self care enables physicians (clinicians) to care for their patients in a sustainable way with greater compassion, sensitivity, effectiveness, and empathy.” “The heart must first pump blood to itself.” (Kearney M. JAMA. 2009;301(11):1157)

6. Lack of self-care may have serious professional & personal consequences

7. Objectives • Define compassion fatigue and burnout and their causes and consequences. • Address risk factors. • Recognize burnout and compassion fatigue in oneself. • Become familiar with what individuals and organizations may do to prevent and alleviate burnout and compassion fatigue.

8. Compassion Fatigue • Experience of emotional depletion due to the suffering of another • Secondary or vicarious traumatization • Evolves from the relationship of the clinician with the patient in the setting of an imbalance of self-care and care of others (Figley CR. Compassion Fatigue, 1995.)

9. Symptoms of Compassion Fatigue: Like Those of Post-Traumatic Stress Disorder • Hyper-arousal: irritability, disturbed sleep, hyper-vigilance • Avoidance:“not wanting to go there” • Re-experiencing: intrusive thoughts or dreams, psychological or physiological distress of reminders of work with dying or suffering (Figley CR. Compassion Fatigue, 1995)

10. WHAT CHARACTERIZES BURNOUT? • Overwhelming emotional and interpersonal job stresses that create an imbalance of professional demands and rewards • Arises from stresses of the clinician’s interaction with the work environment • Results in frustration, powerlessness, and inability to achieve work goals

11. Manifestations of Burnout • Emotional Exhaustion: - Depletion - Irritability/anger - Depression/guilt • Depersonalization: - Cynicism - Feelings of resentment - Withdrawal • Reduced sense of personal accomplishment: - Negative self-concept - Complaining without offering a solution (Maslach, Schaufeli, Leiter, Annual Reviews Psychology 2001)

12. Distinction Between Burnout and Depression • Burnout only involves a person’s relationship to his or her work • Depression globally affects a person’s life (Maslach C, Jackson SE, Leiter MP. Burnout Inventory Manual. 3rd ed. Palo Alto, California: Consulting Psychologists Press, 1996)

13. Exhaustion • Experienced, but also  • Prompts action to distance oneself emotionally and cognitively from one’s work as a way to cope

14. Depersonalization • Coping mechanism of distancing oneself from those one cares for- • Results in failing to appreciate the qualities which make recipients unique and engaging people

15. Reduced Sense of Personal Accomplishment • May develop in parallel, rather than sequentially with exhaustion and depersonalization • Contributor: Lack of relevant resources rather than work overload and social conflict

16. The Six Areas of Work Life • Workload • Control • Reward • Community • Fairness • Values (Maslach D, Leiter MP. 1997 The Truth about Burnout. San Francisco: Jossey-Bass)

17. The “Match/Mismatch” Theoretical Framework of Burnout: • Of six domains of job: • Greater the gap or mismatch, greater the likelihood of burnout • Greater the fit, the greater the likelihood of engagement with work (Maslach and Leiter. The Truth About Burnout.)

18. Varying Importance of the Six Components of Work • Not clear how much of a mismatch people are able to tolerate: May depend on: -Particular area -Pattern of other areas For example, with meaningful rewards, enjoyable working relationship with colleagues, feeling that work is appreciated, people may tolerate much greater workload (Maslach and Leiter. The Truth About Burnout)

19. Personal Consequences of Burnout • Stress, Anxiety, Anger, Depression • Substance abuse • Family disruption • Stress-related health problems (Maslach, Schaufeli, Leiter. Job burnout. Annual Reviews Psychology. 2001)

20. Pathologic Associations with Burnout • Increased incidence of cardiovascular disease, Type 2 diabetes, impaired fertility, poor self-rating of health • Psychoneuroimmunological mechanisms  inflammation • In women, burnout associated with higher CRP and fibrinogen levels • In men, CRP and fibrinogen levels associated with depression (Mayer and Watkins, 1998; Toker el al. 2005)

21. Self-Care Not So Soft After All • Depression in: 12% of male physicians, 18% of female physicians; 15-30% of medical students and residents • After accidents, suicide is the most common cause of death among medical students • Doctors and nurses at higher risk for suicide • Doctors 70% higher mortality rates from self-inflicted injury (Frank et al. 2000) • As many as 400 physicians commit suicide each year in the United States. (Alessandra Strada, PhD. AAHPM meeting, 2009)

22. “Physicians (clinicians) are not merely bearers of knowledge and skills, vitally important as those are, but are themselves the instruments of care.” __Eric Cassell, The Nature of Suffering and the Goals of Medicine, New York: Oxford, 2004

23. Job-Related Consequencesof Burnout • Decreased job performance (Parker, Kulik, J Behav Med 1995) • Reduced commitment to work (Leiter, Harvie, Frizzell. Soc Sci Med 1998) • Low career satisfaction (Goldberg et al. Acad Emerg Med 1996) (Lemkau, Rafferty, Gordon. Fam Pract Res J 1994)

24. Clinical Consequences of Burnout-May Lead to Poor Patient Care • Prolonged hospital stays • Lack of discussion of patients’ and family members’ preferences and goals of care • Patient and family feeling a sense of abandonment • Excessive use of technological interventions

26. Who Is At Risk of Burnout?Professions with Intense Involvement with People • Physicians (rates ranging 25% to 60%) (Gunderson. Ann Intern Med 2001) (Ramirez et al. “Burnout and psychiatric disorder among cancer clinicians” Br J Cancer 1995) • Nurses (Kilfedder, Power, Wells. Soc Sci Med 1998) • Educators (Chernis. Beyond Burnout. NY:Routledge, 1995) • Clergy (Kirk Byron Jones. Rest in the Storm)

27. Risk Factors for Burnout • Being a younger caregivers • Having responsibility for dependents: children or parents • Being single • Being highly motivated with intense investment in one’s profession • Lacking awareness of one’s own physical and emotional needs

28. Risk Factors for Burnout in Medical Residents • Caring for patients with severe illness and suffering • Having limited relationships with patients and families---time, role on health care team • Feeling a need to rescue, fix-it • Facing difficult communication challenges (“get the DNR”)

29. Burnout in Medical Residents • 87 (76%) of internal medicine residents (115 or 76% responding to survey) met criteria for burnout: -More likely to self-report suboptimal patient care which was associated with cynicism and depersonalization (Shanafelt, Bradley, Wipf, Back. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med 2002;136:358-367)

30. Residents’ Self-Reports of Providing Suboptimal Care “I discharged patients to make the service ‘manageable’ because the team was so busy.” “I did not fully discuss treatment options or answer a patient’s questions.” “I ordered restraints or medications for an agitated patient without evaluating.” “I did not perform a diagnostic test because of desire to discharge a patient.” (Shanafelt, AIM, 2002)

31. Self-Reports of Residents Who Experienced Burnout “I paid little attention to the social or personal impact of an illness on a patient.” “I had little emotional reaction to the death of one of my patients.” “I felt guilty about how I treated a patient from a humanitarian standpoint.” (Shanafelt. AIM, 2002)

32. Even Experienced Clinicians May Feel: “a sense of failure and frustration when the patient’s illness progresses, a sense of powerlessness against illness and its associated losses, (unrecognized) grief, a fear of becoming ill oneself, or a desire to separate from and avoid patients to escape these feelings.” (Meier et al. JAMA 2001)

33. “The worst loneliness is to not be comfortable with one’s self.” __Mark Twain

34. Health Care Professionals’ Vulnerability to Burnout • Work closely with patients and families who are intensely suffering, In crisis, and often in conflict The “Lightening Rod Effect” • Conversations require time, focus, and emotional and intellectual energy (Meier and Beresford, J Pall Med, October 2006)

35. Clinicians Experience • Constant exposure to death • Inadequate time with dying patients • Growing workload and increasing deaths • Inadequate coping with one’s own emotional response to dying patients • Need to carry on in wake of patient deaths • Communication challenges with dying patients and relatives • Inability to live up to one’s own standards • Feeling of depression, grief, guilt in response to loss (Kearney MK et al. Self-care of physicians caring for patients at the end of life. JAMA; 2009; 301 (11):1155-1164)

36. Our Challenges We work under pressures of: • Workload • Bureaucratic frustrations (conflict with individualist spirit and values) • Interpersonal conflicts • “Culture of Medicine” (Meier D, Beresford L. J Pall Med, 10/2006)

37. OurVulnerability • Experience feelings of guilt, insecurity, frustration, inadequacy. (A sense of “not being enough”) • Identify with patient or family members may heighten our own sense of grief (Tim) • Be involved in conflicts over goals of care or “agendas” (Meier, Back, Morrison.The inner life of physicians.JAMA, 2001)

38. Recognizing Burnout/Compassion Fatigue in Oneself • Wish to avoid work • Avoidance-rounding when family are not present, when patient not fully awake • Feeling sense of anger and frustration towards patients, families, colleagues • Resisting evaluation for disease progression • Not communicating serious prognoses • Over-dependence on technological life-prolonging interventions

40. Self-Care: Non-Work Related Activities • Enrich ourselves through relationships: ∙ Family ∙ Friends ∙ Patients and their Families . Experience of others

42. Self-Care Activities • Regular exercise, proper nutrition, adequate rest • Take/make time to laugh and relax with friends • Enjoy meaningful solitude-walks, reading, writing, other hobbies

46. Benefits of Maintaining Professional Boundaries • May offer protection from occupational stressors • May foster renewal outside of work (Jackson VA, Mack J, Matsuyama R, et al. J Palliat Med. A qualitative study of oncologists’ approach to end-of-life care. 2008;11(6):893-906)

47. Limitations of Maintaining Professional Boundaries • Clinician may be less emotionally available to patients • Clinician may experience work as less rewarding “may feel as though they are drowning and barely able to come up for air, whereas self-care with self-awareness is like learning to breathe underwater.” (Jackson VA, Mack J, Matsuyama R, et al. J Palliat Med. 2008;11(6):893-906)

48. Return To Our Work

49. Enhancing Self-Care Through Self-Awareness and • Involves self-knowledge and dual-awareness of: - patient and work environment with one’s own subjective experience • Fosters: - job engagement and - less stress with work interactions - empathy as a mutually healing connection with patients - compassion satisfaction and sense of enrichment and growth in witnessing how patients have found meaning and peace as they approach their deaths (vicarious posttraumatic growth) -improved patient care and satisfaction (Kearney M. JAMA, 2009;301(11):1161)

50. “Everything that happens to you is your teacher. The secret is to sit at the feet of your own life and be taught by it.”Polly E. Berends(c/o Alessandra Strada)