Self-care Flashcards
Burnout syndrome
- Loss of enthusiasm for work (emotional exhaustion), sense of being overextended and depleted
- Treating people as if they were objects (depersonalization), callous, cynical, or detached responses to work
- Loss of sense that work is meaningful (Low personal accomplishment), sense of being ineffectual and underachieving
Often arises when individuals are under constant pressure
Types of burnout
Frenetic
- Overinvested
- Working very hard to the sacrifice of personal needs
- Frustrated and distressed by lack of proportionate satisfaction (success, reward, or appreciation)
Under-challenged
- Indifferent as a result of insufficient challenge, stimulation, or meaning from work
Worn-out
- Neglectful due to being overwhelmed by too much work stress and lack of proportionate satisfaction (success, reward, or appreciation)
Symptoms and signs of burnout
Individual
- Overwhelming physical/emotional exhaustion
- Feelings of cynicism or detachment
- Sense of ineffectiveness and lack of accomplishment
- Avoidance of emotionally difficult clinical situations
- Irritability and hypervigilance
- Interpersonal conflicts - overidentification or overinvolvement
- Perfectionism and rigidity
- Poor judgment (boundary violations)
- Social withdrawal
- Numbness and detachment
- Difficulty in concentrating
- Questioning the meaning of life
- Questioning prior religious beliefs
- Sleep problems, intrusive thoughts, nightmares
- Addictive behaviours
- Frequent illness (often non-specific)
Team
- Low morale
- High job turnover
- Impaired job performance (decreased empathy, increased absenteeism)
Contributors to burnout
- Workload
- Control and training
- Sense of personal control over patient care, team dynamics
- May be particularly exacerbated by clinicians with inadequate training particularly around interpersonal skills, specific palliative care skills, and management of compassion fatigue
- Extrinsic factors include work conditions, scheduling, etc. - Interprofessional/Team conflict and issues
- Values
- Greater burnout seen in oncologists who do not value psychosocial aspects of care and relief of physical/psych/spiritual distress (as opposed to curative treatments)
- Moral distress when duties conflict with values
- Distress from an unattainable standard - Reward
- Limited or inadequate financial rewards, or institutional recognition/respect - Emotion-work variables
- Clinicians must be able to emotionally engage while at the same time, not being overwhelmed by suffering or grief - Extrinsic factors (family, financial, social, etc.)
- Personality factors
- Overinvested, highly motivated individuals at higher risk - Age
- Younger caregivers more likely to be burned out - Gender
- Conflicting results
Measures to prevent burnout and compassion fatigue: Personal wellness strategies
- Adequate sleep, nutrition, exercise
- Relaxation built into the day (meditation, massage, deep breathing, etc.)
- Engaging regularly in a non-work related activity
- Supportive and enjoyable relationships with friends/family
- Good work-life balance to defuse work-related tensions
- Monitor oneself for tendency to become overinvolved
- Finding and allowing adequate personal time to grieve losses that come with losing a patient
- Self-awareness techniques (mindful communication or reflective writing)
- Specific set of coping skills, stress management, etc. to deal with daily challenges
- Psychotherapy or spiritual care as needed, particularly in the case of strong emotional reactions or if reminded of personal losses frequently
- Attending to one’s spiritual needs and developing a philosophy of care that provides personal meaning and purpose
Measures to prevent burnout and compassion fatigue: Professional Development Strategies
- Remember who own’s the problem (don’t make the patient’s problems your own)
- Learn to handle conflict effectively
- Training in communication skills
- Maintain a high level of clinical competence and familiarity with guidelines
- Engaging in peer consultation
- Assertiveness skills (set limits, say no, ask for what you need)
- Clear and consistent to maintain boundaries around vacations, time on call, sustainable workload
- Diversifying one’s workload so that not all professional time involves care to the most distressed patients
- Con ed
- Focusing on positive aspects of one’s own and patient’s experiences
Measures to prevent burnout and compassion fatigue: Organizational strategies
- Adequate resources for the job (supervision, con ed, days off, benefits, positive work environment)
- Scheduling that accommodates work/life balance
- Comforting/soothing physical settings
- Encouraging and supporting choice and control, promoting fairness/justice in the workplace
- Appropriate recognition and reward
- Supportive work community
- Adequate supervision and mentoring
- Respect for the work performed by PC clinicians
- Regular discussions of challenging cases where all team members are encouraged to contribute in a safe, supportive environment
- Mindfulness-based stress reduction for team
Compassion Fatigue
- Emotional impact of working with people involved in traumatic life events
- May be a form of PTSD
Symptoms of Compassion fatigue
- Strong emotions (guilt, sadness, anger)
- Intrusive thoughts/nightmares
- Avoidance
- Feeling numb or frozen
- Feeling isolated or personally responsible
- Mistrust of others
- Increased or decreased sense of power or control
- Cynicism
- Withdrawal from the larger treatment team or personal relationships
- Detachment from emotional situations
- Irritability
- Overidentifying with others distress
Strategies to mitigate compassion fatigue
- Exquisite empathy (highly present, attuned, well-boundaried, heartfelt empathic engagement)
- Resilience (post traumatic growth and finding the positive in others experiences of trauma)
- Grieving strategies (departmental memorial services, journalling, attending a funeral)
- Mindfulness
- Wellness
Moral distress
- Stress reaction characterised by frustration, anger, anxiety
- Occurs when someone knows what is ethically correct but is constrained in acting in accordance with their convictions
Examples:
- Clinical decisions (continued life support when not in the best interest, Full Code requests by terminally ill patients. etc.
- Communication issues (false hope, inadequate information)
- Resources (Interests of the organization override that of the patient due to limited resources or availability)
- Lack of staff time (staff time spending time on admin activities rather than patient care)
- Rules and regulations (When rules constrain a clinician in acting in their best judgment)
Management of moral distress
- Forums to discuss ethically troubling situations
- Open and interactive approach to moral conflict
- Careful attention to team dynamics
- Evaluation of whether constraining factors can be changed and how one might engage with these
- Flexibility in re-conceptualizing a problem to maintain a sense of control and understand the differences in reasoning through ethical dilemmas (e.g. patient has a right to be a no code)
- Insight that compromising comes from a place of strength
Mindfulness skills
- Notice and observe sensations, thoughts, and feelings (even if unpleasant)
- Ability to lower one’s tendency to respond reactively to emotionally charged experiences
- Enhanced ability to react with awareness and intention rather than being on reactive autopilot
- Focussing on the experience, not the labels or judgments we apply to them (feel the feeling, don’t label right or wrong)
Mindful practice in medicine (four qualities)
- Attentiveness
- Observe without making judgments that distort ability to understand - Critical curiosity
- Ability to open up to possibilities, rather than premature closure - Informed flexibility (‘beginner’s mind)
- Adopt a fresh perspective of consider more than one perspective simultaneously rather than taking a single fixed view - Presence
- Being there physically, mentally, and emotionally for patients
Reflective writing
- Diarize challenging/rewarding clinical encounters
- Record personal thoughts and objective clinical data - Share and explore narratives in small group discussions or in one on one debriefing
- Focus upon a reflective/evaluative approach to understanding one’s thoughts, thought processes, feelings, and responses
Aim - foster better self understanding and mindfulness skills
Human rights laws relevant to Palliative Care
- Right to health
- Right to dignity (promotion of dignity of the individual patient)
- Right not to be subjected to inhuman or degrading treatment (promotion of appropriate treatment, pain management with opioids, etc.)
- Right to non-discrimination and equality (equal access to palliative care services to all)
- Right to seek, receive, and impart information (access to information on palliative care, palliative treatments, etc.)
- Rights of all children to access health care
- Right to health in older persons
Counter arguments to pain management and palliative care being basic human rights
- Individual human rights do not supersede that of the collective
- A right to palliative care cannot be separated from a general right to health - many aspects of health are inadequately addressed and palliative care must be implemented along with other public health measures (adequate food, housing, etc.)
Practical application of a human rights perspective of palliative care:
- Does the nation have pain/palliative care policies?
- To what extent are opioids available and accessible for those receiving palliative care?
- Does the nation report their annual opioid requirements for medical purposes to the International Control Board, and are these reports commensurate with need?
- Are health professionals educated in management of patients with life-limiting illness and safe/appropriate use of opioids?
- Are palliative care services integrated across all levels of healthcare?
Confidentiality: Definition
- Goal is to maintain confidence/trust in the relationship between patient and provider
- Confidentiality is practices and behaviours strengthening the trust and confidence between patients and HCPs, with special attention to the use of any and all information disclosed by/obtained from patients during their care
Benefits of respecting confidentiality
- Patient has more trust and confidence, more likely to adhere to treatments
- Disclosures are more likely to be honest when a patient can trust the care provider, leading to optimal patient outcomes and improved patient safety
- Respects integrity and personhood
How to respect confidentiality
- Establish and follow organization practices that govern and respect confidentiality (disclosure, record keeping, communication)
- Be clear and explicit with patients and families about principles and practices related to confidentiality (who will have access to what information, why, what is confidential and what is not, what kind of information must be shared and when?)
- Immediately inform patients when breaches of confidentiality occur, as well as take action to mitigate damages caused by such breaches
Definition of ‘truth telling’
- Patient right to information about their illness
- Previously, care providers would shield patients from ‘harsh reality’, whereas now, disclosure is considered a legal and ethical responsibility
- Considerable variability around the globe, but cultural origin and affiliation do not accurately predict preferences, which are very individual
News and how it affects consent/capacity
Frame-altering news and grief
- Patients who have just received significant news can alter decision making, even if not capacity for consent
- Over time, patients adjust to illness/loss/grief through comprehension, creative adaptation (experimentation with living under new circumstances), and finally reintegration (consolidation of a revised way of being)
- Physicians must recognise and anticipate grief, as well as how it may affect consent/decision making
Shared decision-making
- Therapeutic relationship conceptualised as a partnership, where patients and providers have different but equally valuable perspectives and roles in the medical encounter
- Family engagement is also an important aspect of decision making in the palliative care context