Self care of Physicians Caring for Patients at End of Life Palliative Care Journal Club Dr. Judy Littleford MD, FRCPC September 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)

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

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

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, FRCPC September 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 P rovides a good synthesis of ideas Includes web resources

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

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

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

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

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

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."

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

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)

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

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 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

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

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

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

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

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)

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

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: 564-70 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

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

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

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

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

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

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

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

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

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

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

Further discussion…

Further discussion…