Journal Club - Review of Self Care in Palliative Medicine article
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Journal Club - Review of Self Care in Palliative Medicine article

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Palliative Medicine Journal Club review of JAMA 2009;301(11):1155-1164 article: Self Care of Physicians caring for patients at the End of Life

Palliative Medicine Journal Club review of JAMA 2009;301(11):1155-1164 article: Self Care of Physicians caring for patients at the End of Life

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  • 1. Self care of Physicians Caring for Patients at End of Life Palliative Care Journal Club Dr. Judy Littleford MD, FRCPC September 15th, 2009
  • 2. 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)
  • 3. 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
  • 4. 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
  • 5. Self care of Physicians Caring for Patients at End of Life Palliative Care Journal Club Dr. Judy Littleford MD, FRCPC September 15th, 2009
  • 6. http://www.statisticssolutions.com/professional-quality-of-life-scale
  • 7. 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
      • P rovides a good synthesis of ideas
      • Includes web resources
  • 8. 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
  • 9. 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):1071-8 Health care manage review 2008;33(1):29-39
  • 10. 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 & S J occupational behaviour 1981;2:99-113 (original Maslach burnout questionnaire) http://www.rci.rutgers.edu/~sjacksox/PDF/EvaluatingStress.pdf
  • 11. 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
  • 12. 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)
  • 13. 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
  • 14. Work Environment Stressors in Palliative Care
    • 3 references, same lead author (Vachon)
      • C onstant 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
  • 15. Rewards in 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
  • 16. 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. f eelings 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
  • 17. 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
  • 18. Results: Factors Mitigating Burnout Davidson, Kabat-Zinn, Psychosom Med 2003;65: 564-70 Neuroreport 2005;16(17):1893 J Gen Intern Med 2005;20(7):559
    • Jon Kabat-Zinn PhD
    • Mindfulness-Based Stress Reduction Model (since 1979)
    • Original work to help patients tap their own deepest inner resources for learning, growing, healing, transformation
    • Recent randomized clinical trial showed (+) changes in:
    • brain activity
    • immune function
    • emotional processing under stress
  • 19. 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
  • 20. 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):105 Int J Stress Manag 2005;12(2):164 Am Psychol 2006;61(7):305 J Behav Med 1998;21(6):581
  • 21.  
  • 22. 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
  • 23. 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
  • 24. Discussion
    • Major strengths of this paper
      • R eadability
      • 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
  • 25.
    • Further discussion…