Pulling the thread on the sweater: The significance of trauma-informed practices in the provision of palliative care in a critical care setting.

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Deborah George
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1 Pulling the thread on the sweater: The significance of trauma-informed practices in the provision of palliative care in a critical care setting. Dr. Kathleen T. Grimm, MHSc & Sandra Lauer, RN, BSN

2 Objectives Broaden understanding of the definition and universality of trauma Identify interventions to alleviate &/or eliminate residual effects of trauma on patients, families, and care providers Recognize root causes of Moral Injury & Moral Distress Learn self-care practices to incorporate into your daily routine

3 Definitions of Trauma Physical trauma refers to a physical injury. In medicine, however, the words trauma patient usually refer to someone who has suffered serious and lifethreatening physical injury potentially resulting in secondary complications such as shock, respiratory failure and death.

4 Psychological Trauma Determined by EVENTS A person s experience of the event or the ongoing situation. more importantly Trauma is when we have encountered an out of control, frightening experience that has disconnected us from all sense of resourcefulness or safety or coping or love. (Tara Brach, 2011) *

5 Secondary Trauma Compassion fatigue, also known as secondary traumatic stress (STS), is a condition characterized by a gradual lessening of compassion over time. It is common among individuals that work directly with trauma victims such as, nurses, psychologists, first responders, animal welfare workers, health unit coordinators and anyone who helps out others, especially family members, relatives, and other informal caregivers of patients suffering from a chronic illness.

6 Defining Trauma : DSM-IV-TR Post-Traumatic Stress Disorder The development of characteristic symptoms, following exposure to a traumatic stressor involving direct personal experience or witnessing another persons experience of: Actual or threatened death Actual or threatened serious injury Threat to physical integrity Person s response involves intense fear, horror and helplessness leading to extreme stress that overwhelms the person s capacity to cope

7 MINDFULNESS goay4

8 The Adverse Childhood Experiences (ACE) Study Center for Disease Control and Kaiser Permanente (an HMO) Collaboration Over a ten year study involving 17,000 people Looked at effects of adverse childhood experiences (trauma) over the lifespan Largest study ever done on this subject

9 ACE Study Findings 1 in 6 men have experienced emotional trauma 80% of people in psychiatric hospitals have experienced physical or sexual abuse 66% of people in substance abuse treatment report childhood abuse or neglect 90% of women with alcoholism were sexually abused or suffered severe violence from parents

10 Trauma By The Numbers Approximately 7.7 million American adults age 18 and older, or about 3.5 percent of people in this age group in a given year, have PTSD. 51% of the general population have experienced trauma in childhood. 98% of people served by behavioral health have experienced trauma. In one study, approximately 85% of emergency room nurses met the criteria for compassion fatigue. (Dominguez-Gomez & Rutledge, 2009, p. 203). 78% of hospice nurses in another study met the criteria for secondary traumatic stress/compassion fatigue. Abendroth M, Flannery J. Predicting the risk of compassion fatigue: a study of hospice nurses. J Hosp Palliat Nurs. 2006;8(6):

11 Triggering events

12 What is Trauma Informed Care? The Paradigm Change Basic premise for organizing services is transformed from: What is wrong with you? to: What has happened to you? Change starts with an organizational shift from a traditional top-down environment to one that is based on collaboration with those who have experienced trauma and their families National Center for Trauma Informed Care, SAMHSA

13 I woke up in Intensive Care Cro

14 Impact of the Critical Care Environment on the Patient Environment of The Intensive Care Unit: Physical Features Emotional Features Patient Environment Interface: Anxiety Assessment Sleep Assessment Delirium Assessment The Vicious Cycle: Anxiety, Pain, and Sleeplessness Creating a Healing Intensive Care Unit Environment Controlling Excessive Noise and Lights Using Nonpharmacological Therapies Promoting Sleep Family Visiting Family Presence at the End of Life

15 The Cost of Caring

Moral Distress Beyond the emotional residue, moral distress

interpersonal and professional relationships.

16 Moral Distress Beyond the emotional residue, moral distress affects job performance, job satisfaction, and interpersonal and professional relationships. Often manifests in job dissatisfaction and detachment. Journal of Nursing Education and Practice, 2014, Vol. 4, No. 6 :Critical care nurses moral distress in end-of-life decision making

Moral Distress This distress induces feelings of sadness, frustration, anger, guilt, low self-esteem, depression and anxiety www.sciedu.

17 Moral Distress This distress induces feelings of sadness, frustration, anger, guilt, low self-esteem, depression and anxiety Journal of Nursing Education and Practice, 2014, Vol. 4, No. 6 :Critical care nurses moral distress in end-of-life decision making

18 Nurses experiences of ethical challenges Nurses and others that provide care may move, From painful busyness to emotional immunization Nurs Ethics , first published on January 24, 2016

19 Cognitive, emotional and behavioral related stress warning signs Inability to concentrate Repeated thoughts about a traumatic situation Feeling numb or withdrawn Intense irritability Keeping busy to avoid thinking of about a traumatic situation Using alcohol or drugs to relax

20 Distinguishing Compassion Fatigue From Burnout Table 3. Characteristics Differentiating Burnout From Compassion Fatigue Variable Burnout Compassion Fatigue Etiology Reactional: response to work or environmental stressors (i.e., staffing, workload, managerial decision making, inadequate supplies or resources) Relational: consequences of caring for those who are suffering (i.e., inability to change course of painful scenario or trajectory) Chronology Gradual, over time Sudden, acute onset Outcomes Decreased empathic responses, withdrawal; may leave position or transfer Continued endurance or giving results in an imbalance of empathy and objectivity; may ultimately leave position Sources: Alkema et al., 2008; Bush, 2009; Coetzee & Klopper, 2010; Figley, 1995; Najjar et al., 2009; Pfifferling & Gilley, 2000; Sabo, 2006; Sabo, 2008; Showalter, 2000; Yoder, 2010

Acknowledge your stressors. The first step in good self care for those in this type of environment is to identify that it s tough and may be negatively impacting you. Talk about it.

21 Acknowledge your stressors. The first step in good self care for those in this type of environment is to identify that it s tough and may be negatively impacting you. Talk about it. Process your experience with others in your field or some type of support network, including appropriate family and friends. You are not expected to be invincible. Take breaks. Take your allotted breaks and make the best of them. Get outside for some fresh air, stretch and take deep breaths all the way into your belly or just sit and relax with your eyes closed for a few minutes. Get enough sleep and eat healthily. For the tough work you do. Sleep deprivation and poor eating habits will not facilitate your ability to perform as well.

22 Attitude of Gratitude hwiyw

23 The ICU Diaries UVw

Emergency Medical Workers Pause After Traumatic Death This pause honors those lives that do not get saved and gives us a moment to contemplate the

24 Emergency Medical Workers Pause After Traumatic Death This pause honors those lives that do not get saved and gives us a moment to contemplate the passage and bring the sacred into what is often a profane environment. In so doing, we recognize this sad rite of passage. (Jonathan Bartels, 2015)

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26 Questions or Dessert?

Burnout in Palliative Care. Palliative Regional Rounds January 16, 2015 Craig Goldie

Burnout in Palliative Care. Palliative Regional Rounds January 16, 2015 Craig Goldie Burnout in Palliative Care Palliative Regional Rounds January 16, 2015 Craig Goldie Overview of discussion Define burnout and compassion fatigue Review prevalence of burnout in palliative care Complete