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

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Journal Club - Review of Self Care in Palliative Medicine article

  1. 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. 2. Self care of Physicians Caring for Patients at End of Life <ul><li>Kearney MK , Weininger RB, Vachon MLS, Harrison RL, Mount BM </li></ul><ul><ul><li>Corresponding author visiting Professor at Santa Barbara Cottage Hospital & McGill, originally trained in Palliative Care in Ireland ( MB BCH BAO FRCPI) ~ 1980-86 </li></ul></ul><ul><ul><li>First qualified Palliative Specialist in Ireland, Palliative Care Consultant & Medical Director in Dublin until 2003 </li></ul></ul><ul><ul><li>Has training in psychoanalysis, spiritual healing, dreamwork </li></ul></ul><ul><ul><li>Introduced “Healing in Medicine” into the undergraduate medical curriculum at McGill </li></ul></ul><ul><ul><li>Modest publication record (4 peer-reviewed articles, 1 book, 4 book chapters) </li></ul></ul><ul><ul><ul><li>3 Canadians : Vachon (Toronto), Harrison (Vancouver), Mount (Montreal) </li></ul></ul></ul>
  3. 3. Importance of the topic: Self-care <ul><li>Personal reasons </li></ul><ul><ul><li>Lengthy history of intense investment in work/study </li></ul></ul><ul><ul><li>A new career focus provides an opportunity for self-reflection </li></ul></ul><ul><li>Reasons presented by the authors </li></ul><ul><ul><li>Essential part of the therapeutic mandate </li></ul></ul><ul><ul><li>Enables physicians to care for patients in a sustainable way with greater compassion, sensitivity, effectiveness & empathy </li></ul></ul>
  4. 4. Objectives <ul><li>Examine burnout & compassion fatigue </li></ul><ul><ul><li>Define & discuss contributing factors </li></ul></ul><ul><ul><li>Review presenting signs & symptoms </li></ul></ul><ul><li>Present evidence for prevention of burnout & compassion fatigue </li></ul><ul><li>Explore the practice of empathy </li></ul><ul><li>Offer an approach to maximize physician wellness through self-awareness in the setting of caring for patients with end-stage illness </li></ul><ul><li>Discuss practical applications of self-care in the workplace </li></ul>
  5. 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. 6.
  7. 7. Literature review <ul><li>Literature review presented in article is: </li></ul><ul><ul><li>Up to date </li></ul></ul><ul><ul><li>Draws from oncology, palliative medicine, psychotherapy and trauma literature because of their belief that physicians in these fields face similar challenges & rewards </li></ul></ul><ul><ul><li>P rovides a good synthesis of ideas </li></ul></ul><ul><ul><li>Includes web resources </li></ul></ul>
  8. 8. Methods: ethical considerations <ul><li>Ethical considerations </li></ul><ul><ul><li>Financial disclosures: None reported </li></ul></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>The funding agency played no role in the collection, analysis and interpretation of data, or in the preparation of the manuscript </li></ul></ul>
  9. 9. Burnout <ul><li>Environment Clinician </li></ul><ul><li>Overwhelming workload, little support, role conflict, ambiguity, lack of control, loss of autonomy </li></ul><ul><li>Form of mental distress manifested by decreased work performance </li></ul><ul><li>Associated with suboptimal patient care, medical errors, lower patient satisfaction, longer post-discharge recovery </li></ul>JAMA 2006;296(9):1071-8 Health care manage review 2008;33(1):29-39
  10. 10. Burnout signs & symptoms <ul><li>Emotional exhaustion - feeling overextended & depleted </li></ul><ul><li>Depersonalization - detachment from the job, negative or callous responses </li></ul><ul><li>Sense of ineffectiveness – feelings of incompetence or underachievement at work </li></ul><ul><li>Cynicism (not part of the 22 item Maslach Burnout Inventory) </li></ul><ul><ul><li>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.&quot; </li></ul></ul>See Table 1, page 1157 for comprehensive list of S & S J occupational behaviour 1981;2:99-113 (original Maslach burnout questionnaire)
  11. 11. Burnout Demographics <ul><li>Seen to a greater extent in: </li></ul><ul><ul><li>Younger caregivers, those with added responsibility of children or elderly parents, singles </li></ul></ul><ul><ul><li>Highly motivated health professionals with intense investment in their profession </li></ul></ul><ul><ul><li>Those with a self-destructive pattern of overwork & habitual delay in attending to significant relationships </li></ul></ul><ul><ul><li>Professionals who postpone self renewal activities </li></ul></ul><ul><li>Previous mental health problems (depression) </li></ul><ul><li>Impulsive, intense personality traits </li></ul>
  12. 12. Compassion Fatigue <ul><li>Patient Clinician </li></ul><ul><li>The “cost of caring” for others </li></ul><ul><li>Signs & symptoms: </li></ul><ul><ul><li>Hyperarousal (disturbed sleep, angry outbursts, hypervigilance) </li></ul></ul><ul><ul><li>Avoidance (desire to avoid thoughts, feelings, conversations about pain & suffering) </li></ul></ul><ul><ul><li>Re-experiencing (intrusive thoughts & dreams, distress in response to reminders of work with the dying) </li></ul></ul>
  13. 13. Methods: data collection <ul><li>Epidemiology of burnout in oncology & palliative care – Review of the literature </li></ul><ul><li>Topic of interest in 23/112 papers cited </li></ul><ul><ul><li>18 published in 2000 or later </li></ul></ul><ul><ul><li>2 international studies (UK, Japan) comparing palliative physicians & oncologists found less stress amongst the former </li></ul></ul><ul><ul><ul><li>Postulate palliative physicians work with team support </li></ul></ul></ul><ul><ul><ul><li>Oncologists begin from the initial premise of hope </li></ul></ul></ul>
  14. 14. Work Environment Stressors in Palliative Care <ul><li>3 references, same lead author (Vachon) </li></ul><ul><ul><li>C onstant exposure to death </li></ul></ul><ul><ul><li>Inadequate time with dying patients </li></ul></ul><ul><ul><li>Growing workload </li></ul></ul><ul><ul><li>Inadequate coping with one’s own emotional response to dying patients </li></ul></ul><ul><ul><li>Identification with or developing friendships with patients </li></ul></ul><ul><ul><li>Communication difficulties with patients/relatives </li></ul></ul>
  15. 15. Rewards in Palliative care <ul><li>Appreciation of the reciprocal healing process which occurs through meaningful caregiver-patient relationships </li></ul><ul><ul><li>Opportunity for inner self reflection </li></ul></ul><ul><ul><li>Connection with peers, family & community </li></ul></ul><ul><ul><li>Heightened sense of spirituality </li></ul></ul><ul><ul><li>Both biomedical & psychosocial aspects of care </li></ul></ul><ul><li>Rewards less likely if: </li></ul><ul><ul><li>Physician role is primarily biomedical </li></ul></ul><ul><ul><li>Job engagement not possible </li></ul></ul>JAMA 2006;296:1071
  16. 16. Results: Factors Mitigating Burnout <ul><li>Having some control over personal schedule & hours worked </li></ul><ul><li>Practising in teams with shared responsibility/leadership for clinical decision-making </li></ul><ul><li>Job engagement </li></ul><ul><ul><li>Sustainable workload, appropriate recognition. f eelings of choice & control, supportive work community, fairness & justice, meaningful work </li></ul></ul><ul><li>Spirituality </li></ul><ul><li>Enhanced self-awareness (Meditation & Reflective writing) </li></ul>See Table 2 for List of measures that may help prevent burnout
  17. 17. Self Awareness versus Self Care <ul><li>Self care, an example of which is maintaining clear professional boundaries, offers protection from occupational stressors </li></ul><ul><li>Self care without self awareness results in a clinician who is less emotionally available & who finds work less rewarding </li></ul><ul><li>Self awareness involves self knowledge & simultaneous attention to the patient, work environment & one’s own subjective experience, in the moment (Reflective) </li></ul><ul><li>Self awareness expands one’s range of choices & allows for more creative responses in any given situation </li></ul>
  18. 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 <ul><li>Jon Kabat-Zinn PhD </li></ul><ul><li>Mindfulness-Based Stress Reduction Model (since 1979) </li></ul><ul><li>Original work to help patients tap their own deepest inner resources for learning, growing, healing, transformation </li></ul><ul><li>Recent randomized clinical trial showed (+) changes in: </li></ul><ul><li>brain activity </li></ul><ul><li>immune function </li></ul><ul><li>emotional processing under stress </li></ul>
  19. 19. Mindfulness Meditation Practice <ul><li>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 </li></ul><ul><li>Raises a physician’s consciousness of their inner reality (physical, emotional, cognitive) and of the external reality with which they are interacting </li></ul><ul><li>Helps develop a kind, objective witnessing attitude toward self & empathy for others </li></ul>
  20. 20. Mindfulness Meditation Practice <ul><li>Psychological benefits </li></ul><ul><ul><li>Anxiety reduction </li></ul></ul><ul><ul><li>Enhanced sense of well-being </li></ul></ul><ul><ul><li>Alleviation of pain </li></ul></ul><ul><ul><li>Increased self-compassion & empathy for others </li></ul></ul><ul><ul><li>Greater sense of: </li></ul></ul><ul><ul><ul><li>Self-actualization </li></ul></ul></ul><ul><ul><ul><li>Self-responsibility </li></ul></ul></ul><ul><ul><ul><li>Self-directedness </li></ul></ul></ul>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 <ul><li>Practice of exquisite empathy </li></ul><ul><li>Defined as </li></ul><ul><ul><li>“ Highly present, sensitively attuned, well-boundaried, heartfelt empathetic engagement” </li></ul></ul><ul><li>Invigorates rather than depletes </li></ul><ul><li>Refutes the commonly held notion that being empathic to dying patients leads to emotional depletion </li></ul><ul><li>Facilitated by self-awareness </li></ul>No access to cited references
  22. 23. Discussion <ul><li>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 </li></ul><ul><li>Formal & informal methods are available </li></ul><ul><li>Throughout the article, major findings are interpreted and discussed in the context of prior research </li></ul>Suggestions for practicing self-care and self-awareness are listed in Table 3, page 1161
  23. 24. Discussion <ul><li>Major strengths of this paper </li></ul><ul><ul><li>R eadability </li></ul></ul><ul><ul><li>Synthesis of ideas </li></ul></ul><ul><ul><li>Review of the available literature by seasoned practitioners in palliative care </li></ul></ul><ul><ul><li>Offers web-based resources </li></ul></ul><ul><ul><li>Importance of the subject matter </li></ul></ul><ul><li>No identified weaknesses </li></ul><ul><li>Provides « food for thought » applicable at an administrative level, at a time when the PM division is undergoing rapid expansion & evolution </li></ul>
  24. 25. <ul><li>Further discussion… </li></ul>