Sustaining Our Ability to Provide Palliative Care Palliative Care Update 2009 Palliative Care Update...

Sustaining Our Ability Sustaining Our Ability

to Provide to Provide Palliative CarePalliative Care

Palliative Care Update 2009Palliative Care Update 2009

David F. Giansiracusa, MDDavid F. Giansiracusa, MD

Director, Palliative Care ProgramDirector, Palliative Care Program

Maine Medical CenterMaine Medical Center

Portland, MainePortland, Maine

I have no relevant financial I have no relevant financial relationships to disclose.relationships to disclose.

David F. Giansiracusa, David F. Giansiracusa, M.D.M.D.

Why discuss compassionWhy discuss compassion

fatigue, burnout, and fatigue, burnout, and

self-care at a Palliative self-care at a Palliative

Care symposium ?Care symposium ?

“ “Physicians (clinicians) working with patients Physicians (clinicians) working with patients at the end of life frequently have to respond at the end of life frequently have to respond to overwhelming human suffering….Self care to overwhelming human suffering….Self care is an essential part of the therapeutic is an essential part of the therapeutic mandate. Self care enables physicians mandate. Self care enables physicians (clinicians) to care for their patients in a (clinicians) to care for their patients in a sustainable way with greater compassion, sustainable way with greater compassion, sensitivity, effectiveness, and empathy.” sensitivity, effectiveness, and empathy.”

““The heart must first pump blood to itself.”The heart must first pump blood to itself.”

(Kearney M. (Kearney M. JAMA. JAMA. 2009;301(11):1157)2009;301(11):1157)

Lack of self-care mayLack of self-care may

have serious professional have serious professional

& personal consequences& personal consequences

ObjectivesObjectives Define compassion fatigue and Define compassion fatigue and

burnout and their causes and burnout and their causes and consequences.consequences.

Address risk factors. Address risk factors. Recognize burnout and compassion Recognize burnout and compassion

fatigue in oneself.fatigue in oneself. Become familiar with what individuals Become familiar with what individuals

and organizations may do to prevent and organizations may do to prevent and alleviate burnout and compassion and alleviate burnout and compassion fatigue.fatigue.

Compassion FatigueCompassion Fatigue

Experience of emotional depletion due to the Experience of emotional depletion due to the suffering of anothersuffering of another

Secondary or vicarious traumatization Secondary or vicarious traumatization Evolves from the relationship of the clinician Evolves from the relationship of the clinician

with the patient in the setting of an imbalance with the patient in the setting of an imbalance of self-care and care of othersof self-care and care of others

(Figley CR. (Figley CR. Compassion Fatigue, 1995.)Compassion Fatigue, 1995.)

Symptoms of Compassion Symptoms of Compassion Fatigue: Like Those of Post-Fatigue: Like Those of Post-Traumatic Stress DisorderTraumatic Stress Disorder

Hyper-arousalHyper-arousal:: irritability, disturbed sleep, irritability, disturbed sleep, hyper-vigilancehyper-vigilance

Avoidance:Avoidance: “not wanting to go there”“not wanting to go there” Re-experiencing:Re-experiencing: intrusive thoughts or intrusive thoughts or

dreams, psychological or physiological dreams, psychological or physiological distress of reminders of work with dying or distress of reminders of work with dying or suffering suffering

(Figley CR. (Figley CR. Compassion Fatigue, 1995)Compassion Fatigue, 1995)

WHAT CHARACTERIZES BURNOUT?WHAT CHARACTERIZES BURNOUT?

Overwhelming emotional and Overwhelming emotional and interpersonal job stresses that create interpersonal job stresses that create an imbalance of professional an imbalance of professional demands and rewards demands and rewards

Arises from stresses of the clinician’s Arises from stresses of the clinician’s interaction with the work environmentinteraction with the work environment

Results in frustration, powerlessness, Results in frustration, powerlessness, and inability to achieve work goalsand inability to achieve work goals

Manifestations of BurnoutManifestations of Burnout Emotional Exhaustion:Emotional Exhaustion:

- Depletion- Depletion

- Irritability/anger- Irritability/anger

- Depression/guilt- Depression/guilt Depersonalization:Depersonalization:

- Cynicism- Cynicism

- Feelings of resentment- Feelings of resentment

- Withdrawal- Withdrawal Reduced sense of personal accomplishment:Reduced sense of personal accomplishment:

- Negative self-concept- Negative self-concept

- Complaining without offering a solution- Complaining without offering a solution (Maslach, Schaufeli, Leiter, (Maslach, Schaufeli, Leiter, Annual Reviews PsychologyAnnual Reviews Psychology 2001) 2001)

Distinction Between Burnout Distinction Between Burnout and Depressionand Depression

Burnout only involves a person’s Burnout only involves a person’s relationship to his or her workrelationship to his or her work

Depression globally affects a Depression globally affects a person’s lifeperson’s life

(Maslach C, Jackson SE, Leiter MP. (Maslach C, Jackson SE, Leiter MP. Burnout Burnout Inventory Manual.Inventory Manual. 3 3rdrd ed. Palo Alto, California: ed. Palo Alto, California: Consulting Psychologists Press, 1996)Consulting Psychologists Press, 1996)

ExhaustionExhaustion

Experienced, but also Experienced, but also

Prompts action to distance oneself Prompts action to distance oneself emotionally and cognitively from emotionally and cognitively from one’s work as a way to copeone’s work as a way to cope

DepersonalizationDepersonalization

Coping mechanism of distancing Coping mechanism of distancing oneself from those one cares for-oneself from those one cares for-

Results in failing to appreciate the Results in failing to appreciate the qualities which make recipients qualities which make recipients unique and engaging peopleunique and engaging people

Reduced Sense of Personal Reduced Sense of Personal AccomplishmentAccomplishment

May develop in parallel, rather than May develop in parallel, rather than sequentially with exhaustion and sequentially with exhaustion and depersonalizationdepersonalization

Contributor: Lack of relevant Contributor: Lack of relevant resources rather than work overload resources rather than work overload and social conflictand social conflict

The Six Areas of Work LifeThe Six Areas of Work Life

Workload Workload Control Control Reward Reward Community Community Fairness Fairness ValuesValues

(Maslach D, Leiter MP. 1997 (Maslach D, Leiter MP. 1997 The Truth about The Truth about Burnout. Burnout. San Francisco: Jossey-Bass)San Francisco: Jossey-Bass)

The “Match/Mismatch” The “Match/Mismatch” Theoretical Framework of Theoretical Framework of

Burnout:Burnout:

Of six domains of job: Of six domains of job: Greater the gap or mismatch, greater Greater the gap or mismatch, greater

the likelihood of burnoutthe likelihood of burnout Greater the fit, the greater the Greater the fit, the greater the

likelihood of engagement with work likelihood of engagement with work

(Maslach and Leiter. (Maslach and Leiter. The Truth About The Truth About Burnout.) Burnout.)

Varying Importance of the Six Varying Importance of the Six Components of WorkComponents of Work

Not clear how much of a mismatch people are Not clear how much of a mismatch people are able to tolerate: able to tolerate:

May depend on: May depend on: -Particular area-Particular area -Pattern of other areas-Pattern of other areasFor example, with meaningful rewards, enjoyable For example, with meaningful rewards, enjoyable

working relationship with colleagues, feeling that working relationship with colleagues, feeling that work is appreciated, people may tolerate much work is appreciated, people may tolerate much greater workloadgreater workload

(Maslach and Leiter. (Maslach and Leiter. The Truth About Burnout)The Truth About Burnout)

Personal Consequences of Personal Consequences of BurnoutBurnout

Stress, Anxiety, Anger, DepressionStress, Anxiety, Anger, Depression Substance abuseSubstance abuse Family disruption Family disruption Stress-related health problemsStress-related health problems

(Maslach, Schaufeli, Leiter. Job burnout. (Maslach, Schaufeli, Leiter. Job burnout. Annual Reviews PsychologyAnnual Reviews Psychology.. 2001) 2001)

Pathologic Associations with Pathologic Associations with Burnout Burnout

Increased incidence of cardiovascular disease, Increased incidence of cardiovascular disease, Type 2 diabetes, impaired fertility, poor self-Type 2 diabetes, impaired fertility, poor self-rating of healthrating of health

Psychoneuroimmunological mechanisms Psychoneuroimmunological mechanisms inflammation inflammation

In women, burnout associated with higher CRP In women, burnout associated with higher CRP and fibrinogen levelsand fibrinogen levels

In men, CRP and fibrinogen levels associated with In men, CRP and fibrinogen levels associated with depressiondepression

(Mayer and Watkins, 1998; Toker el al. 2005)(Mayer and Watkins, 1998; Toker el al. 2005)

Self-Care Not So Soft After Self-Care Not So Soft After AllAll

Depression in: 12% of male physicians, 18% of Depression in: 12% of male physicians, 18% of female physicians; 15-30% of medical students and female physicians; 15-30% of medical students and residentsresidents

After accidents, suicide is the most common cause After accidents, suicide is the most common cause of death among medical studentsof death among medical students

Doctors and nurses at higher risk for suicideDoctors and nurses at higher risk for suicide Doctors 70% higher mortality rates from self-Doctors 70% higher mortality rates from self-

inflicted injury (Frank et al. 2000)inflicted injury (Frank et al. 2000) As many as 400 physicians commit suicide each As many as 400 physicians commit suicide each

year in the United States.year in the United States. (Alessandra Strada, PhD. AAHPM meeting, 2009)(Alessandra Strada, PhD. AAHPM meeting, 2009)

““Physicians (clinicians) are not Physicians (clinicians) are not merely bearers of knowledge merely bearers of knowledge and skills, vitally important as and skills, vitally important as those are, but are themselves those are, but are themselves the instruments of care.”the instruments of care.”

__Eric Cassell, __Eric Cassell, The Nature of Suffering and The Nature of Suffering and

the Goals of Medicinethe Goals of Medicine, New York: Oxford, , New York: Oxford, 20042004

Job-Related ConsequencesJob-Related Consequences of Burnoutof Burnout

Decreased job performanceDecreased job performance (Parker, Kulik, (Parker, Kulik, J Behav MedJ Behav Med 1995) 1995)

Reduced commitment to workReduced commitment to work (Leiter, Harvie, Frizzell. (Leiter, Harvie, Frizzell. Soc Sci MedSoc Sci Med 1998) 1998)

Low career satisfactionLow career satisfaction (Goldberg et al. (Goldberg et al. Acad Emerg MedAcad Emerg Med 1996) 1996)

(Lemkau, Rafferty, Gordon. (Lemkau, Rafferty, Gordon. Fam Pract Res JFam Pract Res J 1994)1994)

Clinical Consequences of Clinical Consequences of Burnout-Burnout-

May Lead to Poor Patient CareMay Lead to Poor Patient Care

Prolonged hospital staysProlonged hospital stays Lack of discussion of patients’ and Lack of discussion of patients’ and

family members’ preferences and family members’ preferences and goals of caregoals of care

Patient and family feeling a sense of Patient and family feeling a sense of abandonmentabandonment

Excessive use of technological Excessive use of technological interventionsinterventions

Who Is At Risk of Burnout?Who Is At Risk of Burnout?Professions with Professions with

Intense Involvement with PeopleIntense Involvement with People Physicians (rates ranging 25% to 60%) Physicians (rates ranging 25% to 60%) (Gunderson. (Gunderson. Ann Intern MedAnn Intern Med 2001) 2001)

(Ramirez et al. “Burnout and psychiatric disorder among(Ramirez et al. “Burnout and psychiatric disorder among

cancer clinicians” cancer clinicians” Br J CancerBr J Cancer 1995) 1995)

NursesNurses (Kilfedder, Power, Wells. (Kilfedder, Power, Wells. Soc Sci MedSoc Sci Med 1998) 1998)

EducatorsEducators

(Chernis. (Chernis. Beyond BurnoutBeyond Burnout. NY:Routledge,. NY:Routledge, 1995) 1995) ClergyClergy (Kirk Byron Jones. (Kirk Byron Jones. Rest in the Storm)Rest in the Storm)

Risk Factors for BurnoutRisk Factors for Burnout

Being a younger caregiversBeing a younger caregivers Having responsibility for dependents: Having responsibility for dependents:

children or parentschildren or parents Being singleBeing single Being highly motivated with intense Being highly motivated with intense

investment in one’s professioninvestment in one’s profession Lacking awareness of one’s own Lacking awareness of one’s own

physical and emotional needsphysical and emotional needs

Risk Factors for Burnout Risk Factors for Burnout in Medical Residentsin Medical Residents

Caring for patients with severe illness Caring for patients with severe illness and sufferingand suffering

Having limited relationships with Having limited relationships with patients and families---time, role on patients and families---time, role on health care teamhealth care team

Feeling a need to rescue, fix-itFeeling a need to rescue, fix-it Facing difficult communication Facing difficult communication

challenges (“get the DNR”)challenges (“get the DNR”)

Burnout in Medical Burnout in Medical ResidentsResidents

87 87 (76%)(76%) of internal medicine of internal medicine residents (115 or 76% responding to residents (115 or 76% responding to survey) survey) met criteria for burnout:met criteria for burnout:

-More likely to self-report suboptimal -More likely to self-report suboptimal patient care which was associated with patient care which was associated with cynicism and depersonalization cynicism and depersonalization

(Shanafelt, Bradley, Wipf, Back. Burnout and self-(Shanafelt, Bradley, Wipf, Back. Burnout and self-

reported patient care in an internal medicine reported patient care in an internal medicine residency program. residency program. Ann Intern MedAnn Intern Med 2002;136:358- 2002;136:358-367)367)

Residents’ Self-Reports of Residents’ Self-Reports of Providing Suboptimal CareProviding Suboptimal Care

““I discharged patients to make the service I discharged patients to make the service ‘manageable’ because the team was so busy.”‘manageable’ because the team was so busy.”

““I did not fully discuss treatment options or I did not fully discuss treatment options or answer a patient’s questions.”answer a patient’s questions.”

““I ordered restraints or medications for an I ordered restraints or medications for an agitated patient without evaluating.”agitated patient without evaluating.”

““I did not perform a diagnostic test because of I did not perform a diagnostic test because of desire to discharge a patient.” desire to discharge a patient.”

(Shanafelt, (Shanafelt, AIMAIM, 2002), 2002)

Self-Reports of Residents Who Self-Reports of Residents Who Experienced BurnoutExperienced Burnout

““I paid little attention to the social or I paid little attention to the social or personal impact of an illness on a personal impact of an illness on a patient.”patient.”

““I had little emotional reaction to the I had little emotional reaction to the death of one of my patients.”death of one of my patients.”

““I felt guilty about how I treated a patient I felt guilty about how I treated a patient from a humanitarian standpoint.”from a humanitarian standpoint.”

(Shanafelt. (Shanafelt. AIMAIM, , 2002)2002)

Even Experienced Clinicians Even Experienced Clinicians May Feel:May Feel:

“ “a sense of failure and frustration a sense of failure and frustration when the patient’s illness progresses, a when the patient’s illness progresses, a sense of powerlessness against illness sense of powerlessness against illness and its associated losses, and its associated losses, (unrecognized) grief, a fear of becoming (unrecognized) grief, a fear of becoming ill oneself, or a desire to separate from ill oneself, or a desire to separate from and avoid patients to escape these and avoid patients to escape these feelings.”feelings.”

(Meier et al. (Meier et al. JAMAJAMA 2001) 2001)

““The worst loneliness is to not The worst loneliness is to not

be comfortable with one’s be comfortable with one’s self.”self.”

____Mark TwainMark Twain

Health Care Professionals’ Health Care Professionals’ Vulnerability to Burnout Vulnerability to Burnout

Work closely with patients and families Work closely with patients and families who are intensely suffering,who are intensely suffering,

In crisis, and often in conflictIn crisis, and often in conflict The “Lightening Rod Effect”The “Lightening Rod Effect” Conversations require time, focus, and Conversations require time, focus, and

emotional and intellectual energy emotional and intellectual energy

(Meier and Beresford, (Meier and Beresford, J Pall MedJ Pall Med, October , October 2006)2006)

Clinicians ExperienceClinicians Experience Constant exposure to deathConstant exposure to death Inadequate time with dying patientsInadequate time with dying patients Growing workload and increasing deathsGrowing workload and increasing deaths Inadequate coping with one’s own emotional Inadequate coping with one’s own emotional

response to dying patientsresponse to dying patients Need to carry on in wake of patient deathsNeed to carry on in wake of patient deaths Communication challenges with dying Communication challenges with dying

patients and relativespatients and relatives Inability to live up to one’s own standardsInability to live up to one’s own standards Feeling of depression, grief, guilt in response Feeling of depression, grief, guilt in response

to lossto loss (Kearney MK et al. Self-care of physicians caring for (Kearney MK et al. Self-care of physicians caring for

patients at the end of life. patients at the end of life. JAMAJAMA; 2009; 301 ; 2009; 301 (11):1155-1164)(11):1155-1164)

Our ChallengesOur Challenges

We work under pressures of:We work under pressures of: WorkloadWorkload Bureaucratic frustrations (conflict with Bureaucratic frustrations (conflict with

individualist spirit and values)individualist spirit and values) Interpersonal conflictsInterpersonal conflicts ““Culture of Medicine”Culture of Medicine”

(Meier D, Beresford L. (Meier D, Beresford L. J Pall Med, J Pall Med, 10/2006)10/2006)

OurOur VulnerabilityVulnerability

Experience feelings of guilt, insecurity, Experience feelings of guilt, insecurity, frustration, inadequacy. frustration, inadequacy.

((A sense of “not being enough”)A sense of “not being enough”) Identify with patient or family members may Identify with patient or family members may

heighten our own sense of grief (Tim)heighten our own sense of grief (Tim) Be involved in conflicts over goals of care or Be involved in conflicts over goals of care or

“agendas”“agendas” (Meier, Back, Morrison.The inner life of physicians.(Meier, Back, Morrison.The inner life of physicians.

JAMAJAMA, 2001), 2001)

Recognizing Recognizing Burnout/Compassion Fatigue in Burnout/Compassion Fatigue in

OneselfOneself Wish to avoid workWish to avoid work Avoidance-rounding when family are not Avoidance-rounding when family are not

present, when patient not fully awakepresent, when patient not fully awake Feeling sense of anger and frustration Feeling sense of anger and frustration

towards patients, families, colleaguestowards patients, families, colleagues Resisting evaluation for disease progressionResisting evaluation for disease progression Not communicating serious prognosesNot communicating serious prognoses Over-dependence on technological life-Over-dependence on technological life-

prolonging interventionsprolonging interventions

Self-Care: Non-Work Self-Care: Non-Work Related ActivitiesRelated Activities

Enrich ourselves through Enrich ourselves through relationshipsrelationships::∙∙ FamilyFamily∙∙ FriendsFriends∙∙ Patients and their FamiliesPatients and their Families

. Experience of others. Experience of others

Self-Care ActivitiesSelf-Care Activities

Regular exercise, proper nutrition, Regular exercise, proper nutrition, adequate restadequate rest

Take/make time to laugh and relax Take/make time to laugh and relax with friends with friends

Enjoy meaningful solitude-walks, Enjoy meaningful solitude-walks, reading, writing, other hobbiesreading, writing, other hobbies

Benefits of Maintaining Benefits of Maintaining Professional BoundariesProfessional Boundaries

May offer protection from May offer protection from occupational stressorsoccupational stressors

May foster renewal outside of workMay foster renewal outside of work

(Jackson VA, Mack J, Matsuyama R, et (Jackson VA, Mack J, Matsuyama R, et al. al. J Palliat Med. A qualitative study J Palliat Med. A qualitative study of oncologists’ approach to end-of-of oncologists’ approach to end-of-life care. life care. 2008;11(6):893-906)2008;11(6):893-906)

Limitations of Maintaining Limitations of Maintaining Professional BoundariesProfessional Boundaries

Clinician may be less emotionally available to Clinician may be less emotionally available to patients patients

Clinician may experience work as less rewardingClinician may experience work as less rewarding “ “may feel as though they are drowning and may feel as though they are drowning and

barely able to come up for air, whereas self-care barely able to come up for air, whereas self-care with self-awareness is like learning to breathe with self-awareness is like learning to breathe underwater.” underwater.”

(Jackson VA, Mack J, Matsuyama R, et al. (Jackson VA, Mack J, Matsuyama R, et al. J Palliat J Palliat Med. Med. 2008;11(6):893-906)2008;11(6):893-906)

Return To Our WorkReturn To Our Work

Enhancing Self-Care Through Enhancing Self-Care Through Self-Awareness and Self-Awareness and

Involves self-knowledge and Involves self-knowledge and dual-awareness ofdual-awareness of::

- patient and work environment with one’s own subjective experience- patient and work environment with one’s own subjective experience Fosters: Fosters:

- job engagement and - job engagement and

- less stress with work interactions- less stress with work interactions

- empathy as a mutually healing connection with patients- empathy as a mutually healing connection with patients

- compassion satisfaction and sense of enrichment and growth in - compassion satisfaction and sense of enrichment and growth in witnessing how patients have found meaning and peace as they approach witnessing how patients have found meaning and peace as they approach their deaths (their deaths (vicarious posttraumatic growthvicarious posttraumatic growth))

-improved patient care and satisfaction-improved patient care and satisfaction

(Kearney M. (Kearney M. JAMA,JAMA, 2009;301(11):1161) 2009;301(11):1161)

““Everything that happens to Everything that happens to you is your teacher. The you is your teacher. The

secret is to sit at the feet of secret is to sit at the feet of your own life and be taught your own life and be taught

by it.”by it.”

Polly E. BerendsPolly E. Berends

(c/o Alessandra Strada)(c/o Alessandra Strada)

Caring for YourselfCaring for Yourself

Identify ways to process intense Identify ways to process intense emotions (share with another, emotions (share with another, meditate, exercise)meditate, exercise)

Attend to your own emotional and Attend to your own emotional and spiritual needs including grieving spiritual needs including grieving your lossesyour losses

Monitor your emotional reactions, Monitor your emotional reactions, assess self for depression—if so, assess self for depression—if so, get help!get help!

Self-AwarenessSelf-Awareness

What are our sources of meaning?What are our sources of meaning? Where are we most vulnerable? Where are we most vulnerable? How do we grieve?How do we grieve? How is the mind-body connection How is the mind-body connection

occurring within us as we work?occurring within us as we work?

Self-AwarenessSelf-Awareness What aspects of work are most What aspects of work are most

gratifying? gratifying?

Relationships with patients Relationships with patients

Teaching Teaching

Research Research

Program developmentProgram development How do professional demands affect us?How do professional demands affect us? How do we view the rewards of our How do we view the rewards of our

work?work?

Potential PitfallsPotential Pitfalls ““It is my nature.”It is my nature.” - Danger: assume that problems cannot occur- Danger: assume that problems cannot occur Professionally trained to deal with emotionsProfessionally trained to deal with emotions - Or trained to suppress/repress/disconnect - Or trained to suppress/repress/disconnect

fromfrom ““It must be so depressing.”It must be so depressing.” - Danger: only focus on rewards, minimize risks- Danger: only focus on rewards, minimize risks ““I don’t know how you do it. I could never do I don’t know how you do it. I could never do

what you do.”what you do.” - Danger: pride, power, ego, idealization- Danger: pride, power, ego, idealization (Alessandra Strada, PhD, AAHPM, 2009)(Alessandra Strada, PhD, AAHPM, 2009)

Self-Care Measures That May Self-Care Measures That May Prevent BurnoutPrevent Burnout

Mindful meditation*Mindful meditation* Reflective Writing*Reflective Writing* Training in communication skillsTraining in communication skills Development of self-awareness skillsDevelopment of self-awareness skills Practice of self-care activitiesPractice of self-care activities Continued educational activitiesContinued educational activities Participation in researchParticipation in research Mindfulness-based stress reduction and meaning-Mindfulness-based stress reduction and meaning-

centered interventions for teamcentered interventions for team *evidence for enhancing self-awareness*evidence for enhancing self-awareness

(Kearney M et al. (Kearney M et al. Self-care of physicians caring for patients at Self-care of physicians caring for patients at the end of life. JAMA, the end of life. JAMA, 2009;301(11):1155-64)2009;301(11):1155-64)

Mindfulness MeditationMindfulness Meditation The practice of careful attention to minute shifts in The practice of careful attention to minute shifts in

body, mind, emotions, and environment while holding body, mind, emotions, and environment while holding a kind, non- judgmental attitude toward self & othersa kind, non- judgmental attitude toward self & others

Fosters development of:Fosters development of: - a kind, objective witnessing attitude- a kind, objective witnessing attitude - empathy for others- empathy for others - compassion for self- compassion for self Reduces anxiety and enhances sense of well-beingReduces anxiety and enhances sense of well-being (Kabat-Zinn J. (Kabat-Zinn J. Clin Psychol Sci Proc. Clin Psychol Sci Proc. 2003;10(2):144-155;2003;10(2):144-155; Grossman P. et al.Grossman P. et al.J Pyschosom Res.J Pyschosom Res. 2004;57(1):35-43 2004;57(1):35-43

Reflective WritingReflective Writing

Writing in a reflective and emotionally Writing in a reflective and emotionally expressive wayexpressive way

Promotes reflection and empathetic Promotes reflection and empathetic engagementengagement

(Charon R. (Charon R. Narrative medicine: a model for empathy, Narrative medicine: a model for empathy, reflection, profession, and trust. JAMA. reflection, profession, and trust. JAMA. 2001;286(15):1897-2001;286(15):1897-1902;1902;

Pennebaker JW. Pennebaker JW. Opening Up: The Healing Power of Expressive Opening Up: The Healing Power of Expressive Emotions. Emotions. New York, NY: Guilford Press, 1997.)New York, NY: Guilford Press, 1997.)

Self-Care and Self-Awareness Self-Care and Self-Awareness Practices in the WorkplacePractices in the Workplace

(Kearney M et al. (Kearney M et al. JAMA. JAMA. 2009;301(11):1155-11642009;301(11):1155-1164

Walking meditationWalking meditation At scheduled times: At scheduled times: -4 cleansing breaths, -4 cleansing breaths,

-think of a loved-one,-think of a loved-one, -recite a -recite a

poem/prayerpoem/prayer Reward yourself after a Reward yourself after a

task: coffee breaktask: coffee break Attend to nature out of Attend to nature out of

a windowa window Half minute of silence Half minute of silence

or read a poem before or read a poem before meetingmeeting

Cleansing breaths, Cleansing breaths, “acknowledge patient as “acknowledge patient as a fellow traveler”, ask to a fellow traveler”, ask to “make me an instrument “make me an instrument of thy peace” before of thy peace” before patient visitpatient visit

Keep field book/journal Keep field book/journal to write about to write about meaningful or traumatic meaningful or traumatic encounters, and share encounters, and share themthem

Develop end of the Develop end of the workday ritualworkday ritual

Always figure out a way Always figure out a way to touch the patientto touch the patient


Acknowledge: Acknowledge:

Medicine’s limitations and Medicine’s limitations and your own limitations your own limitations

““Be appreciative of your limited Be appreciative of your limited successes, more tolerant of your successes, more tolerant of your limited failures…..limited failures…..

I strive to do the very best, but I I strive to do the very best, but I am pleased with am pleased with

‘ ‘good enough’”.good enough’”.

__J. Andrew Billings__J. Andrew Billings


DO NOT DO IT ALONE-DO NOT DO IT ALONE-

Bring a colleagueBring a colleague

Sharing with ColleaguesSharing with Colleagues

Address “the affect” and share on team Address “the affect” and share on team rounds:rounds:

death of a patientdeath of a patient particular identification with a patient particular identification with a patient

(you, one of your loved-ones: spouse, (you, one of your loved-ones: spouse, child)child)

particularly challenging patient/familyparticularly challenging patient/family being “fired” by patient or familybeing “fired” by patient or family

Caring for Yourself Caring for Yourself

Formal, scheduled support groupsFormal, scheduled support groups Mentoring from more experienced Mentoring from more experienced

practitioner(s)practitioner(s) Participation in team Participation in team

processes/rituals to acknowledge processes/rituals to acknowledge losses and patients who have died-losses and patients who have died-Memorial Services, patient Memorial Services, patient recognition rounds, de-briefings recognition rounds, de-briefings

Personal support system Personal support system (Meier and Beresford, (Meier and Beresford, J Pall MedJ Pall Med, October, , October,

2006)2006)

Renewal: Enhance Our SkillRenewal: Enhance Our Skill

Growth experiences in skill and self-Growth experiences in skill and self-discovery as well as linkages with others:discovery as well as linkages with others:∙∙ Practical Aspects of Palliative Care Practical Aspects of Palliative Care

ConferenceConference∙∙ Palliative Care Education and PracticePalliative Care Education and Practice

(PCEP) program(PCEP) program∙∙ Educating Physicians in End-of-Life Educating Physicians in End-of-Life Care (EPEC)Care (EPEC)

Institute for the Study of Institute for the Study of Health and Illness (ISHI), Health and Illness (ISHI), Commonweal: retreats Commonweal: retreats with Rachel Naomi with Rachel Naomi RemenRemen

RenewalRenewal

““Spirituality and Meaning in Spirituality and Meaning in Medicine” ConferenceMedicine” Conference

Other organizations offering group Other organizations offering group discussions, conferences, retreats:discussions, conferences, retreats:

∙∙ ““Renew”Renew”

∙∙ ““Doctor to Heal”Doctor to Heal”

Renew Our Values and Renew Our Values and Refresh Our Goals and Refresh Our Goals and

SkillsSkills

“ “Looking through new Looking through new eyes” at the work we do eyes” at the work we do and the people we care and the people we care for.for.

““Curing:Curing: Making the problem go away.Making the problem go away. Healing:Healing: Giving people the resources to Giving people the resources to

enjoy life when they cannot make enjoy life when they cannot make the problem go away.”the problem go away.”

__Rabbi Harold Kushner __Rabbi Harold Kushner

Experience how others have Experience how others have dealt with adversity and dealt with adversity and illnessillness

(Suggested (Suggested readings)readings)

““There are two ways of There are two ways of

of spreading light;of spreading light;

To be the candleTo be the candle

Or the mirror that Or the mirror that

reflects it.”reflects it.”

__Edith Wharton__Edith Wharton

Experience the Wonder of Experience the Wonder of Patients, Their Families, Patients, Their Families,

and and our Colleaguesour Colleagues

Love in a familyLove in a family ResilienceResilience CourageCourage Values Values Way patient views his own life and Way patient views his own life and

death death

““Man is not destroyed by Man is not destroyed by

suffering alone,suffering alone,

But by suffering without But by suffering without meaning.”meaning.”

____Viktor Frankl, Viktor Frankl, Man’s Search For Man’s Search For MeaningMeaning

Look within yourself:Look within yourself:

“ “What is hardest for me in What is hardest for me in doing my work?”doing my work?”

“ “What brings me the most What brings me the most joy and meaning in doing my joy and meaning in doing my work?”work?”

Pursue a personal quest to find Pursue a personal quest to find meaning and purpose in life meaning and purpose in life and a relationship to something and a relationship to something greater than oneself....greater than oneself....

The shift from ourselves to The shift from ourselves to caring for others.caring for others.

__Michael Kearney, __Michael Kearney, Mortally WoundedMortally Wounded

““Those who give from the Those who give from the source are nourished in the source are nourished in the giving.”giving.”

__Stephen Levine, __Stephen Levine, Who Who DiesDies

Going deeper:Going deeper:

““Healing requires recognition of Healing requires recognition of the human face of each person the human face of each person one sets to heal and of the one sets to heal and of the message that both the healer and message that both the healer and the healed share a bond that ties the healed share a bond that ties them to each other through their them to each other through their humanity, their mortality, and the humanity, their mortality, and the God-given spark of grace that God-given spark of grace that lives in each of them.”lives in each of them.”

__Daniel P. Sulmasy, __Daniel P. Sulmasy, The Healer’s CallingThe Healer’s Calling

So What Have I Learned?So What Have I Learned?

Self care is extraordinarily important, Self care is extraordinarily important, but may not be sufficient to prevent but may not be sufficient to prevent burnoutburnout

Organizational interventions are Organizational interventions are likely also necessary: a focus on likely also necessary: a focus on workload, control, rewards, workload, control, rewards, community, fairness, and values of community, fairness, and values of work environmentwork environment

Personal Reflection on Self Personal Reflection on Self CareCare

““I learned this, at least, by my I learned this, at least, by my experiment;experiment;

that if one advances confidently in the that if one advances confidently in the direction of his dreams, and endeavors direction of his dreams, and endeavors to live the life which he has imagined,to live the life which he has imagined,

he will meet a success unexpected in he will meet a success unexpected in common hours”common hours”

____Henry David Thoreau, Henry David Thoreau, WaldenWalden

Reflection on Institutional Reflection on Institutional Factors and BurnoutFactors and Burnout

““You’re lucky you work at a You’re lucky you work at a place where the coffee is not place where the coffee is not so bad”so bad”

Family member/visitor comment:

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Blust L. “Health Professional Burnout: Parts Blust L. “Health Professional Burnout: Parts I-IV. Fast Fact and Concept #167-170. 2007, I-IV. Fast Fact and Concept #167-170. 2007, www.eperc.mcw.eduwww.eperc.mcw.edu

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Gundersen L. Physician burnout. Gundersen L. Physician burnout. Ann Ann Intern Med.Intern Med. 135:145-148, 2001. 135:145-148, 2001.

Rabow MW, McPhee SJ. Doctoring to heal. Rabow MW, McPhee SJ. Doctoring to heal. West J Med.West J Med. 174:66-69, 2001. 174:66-69, 2001.

Freudenberger H. Staff burn-out. Freudenberger H. Staff burn-out. J Soc J Soc IssuesIssues 30:159-165, 1974. 30:159-165, 1974.

Mount BM. Dealing with our losses. Mount BM. Dealing with our losses. J Clin J Clin Oncology.Oncology. 4(7):1127-1134, 1986. 4(7):1127-1134, 1986.

Remen RN. Recapturing the soul of Remen RN. Recapturing the soul of medicine. medicine. West J Med.West J Med. 174:4-5, 2001. 174:4-5, 2001.

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life of physicians and care of the seriously life of physicians and care of the seriously ill. ill. JAMA.JAMA. 286(23):3007-3014, 2001. 286(23):3007-3014, 2001.

Jenkins V, Fallowfield L. Can Jenkins V, Fallowfield L. Can communication skills training alter communication skills training alter physicians’ beliefs and behaviors in the physicians’ beliefs and behaviors in the clinics? clinics? J Clin OncJ Clin Onc. 20(3):765-769, 2002. . 20(3):765-769, 2002.

Block SD. Psychological considerations, Block SD. Psychological considerations, growth, transcendence at the end of life: growth, transcendence at the end of life: The art of the possible.The art of the possible. JAMA JAMA 285:2898- 285:2898-2905, 2001.2905, 2001.

Cassell E. The nature of suffering and the Cassell E. The nature of suffering and the goals of medicine. goals of medicine. N Engl J Med.N Engl J Med. 306:639-306:639-645, 1982645, 1982


Shanafelt TD, Bradley KA, Wipf JE, Back AL. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an Burnout and self-reported patient care in an internal medicine residency program. internal medicine residency program. Ann Ann Intern MedIntern Med 136:358-367, 2002. 136:358-367, 2002.

Ramirez AJ, Graham J, Richards MA, et. al. Ramirez AJ, Graham J, Richards MA, et. al. Burnout and psychiatric disorders among Burnout and psychiatric disorders among cancer clinicians. cancer clinicians. Br J CancerBr J Cancer 71:1263-9, 71:1263-9, 19951995

Kilfedder CJ, Power KG, Wells TJ. Burnout in Kilfedder CJ, Power KG, Wells TJ. Burnout in psychiatric nursing. psychiatric nursing. J Adv NursJ Adv Nurs 34:383-96, 34:383-96, 20012001

Leiter MP, Harvie P, Frizzell C. The Leiter MP, Harvie P, Frizzell C. The correspondence of patient satisfaction and correspondence of patient satisfaction and nurse burnout. nurse burnout. Soc Sci MedSoc Sci Med 47:1611-7, 1998 47:1611-7, 1998


Cherniss C. Cherniss C. Beyond Burnout: Helping Beyond Burnout: Helping Teachers, Nurses, Therapists, and Lawyers Teachers, Nurses, Therapists, and Lawyers Recover from Stress and DisillusionmentRecover from Stress and Disillusionment, , New York: Routledge, 1995New York: Routledge, 1995

Goldberg R, Boss RW, Chan L. et al. Burnout and Goldberg R, Boss RW, Chan L. et al. Burnout and its correlates in emergency physicians. its correlates in emergency physicians. Acad Acad Emerg MedEmerg Med 3:1156-64, 1996 3:1156-64, 1996

Lemkau J, Rafferty J, Gordon R Jr. Burnout and Lemkau J, Rafferty J, Gordon R Jr. Burnout and career-choice regret among family practice career-choice regret among family practice physicians in early practice. physicians in early practice. Fam Pract Res JFam Pract Res J 14:213-22, 199414:213-22, 1994

Smith AK, Buss MK, Giansiracusa DF, Block SD. Smith AK, Buss MK, Giansiracusa DF, Block SD. On being fired: Experiences of patient-initiated On being fired: Experiences of patient-initiated termination of the patient-physician relationship termination of the patient-physician relationship in palliative medicine. in palliative medicine. J Palliat Med. J Palliat Med. 10(4):938-10(4):938-947, 2007947, 2007


Sherman DW. Nurses’ stress and burnout. Sherman DW. Nurses’ stress and burnout. Amer. J Nursing.Amer. J Nursing. 104: 48-56, 2004. 104: 48-56, 2004.

Redinbaugh EM, Sullivan AM, Block SD et al. Redinbaugh EM, Sullivan AM, Block SD et al. Doctors’ emotional reactions to recent death Doctors’ emotional reactions to recent death of a patient: cross sectional study of hospital of a patient: cross sectional study of hospital doctors. doctors. British Medical JournalBritish Medical Journal 327:1-6, 26 327:1-6, 26 July 2003.July 2003.

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ReferencesReferences Figley CR ed. Figley CR ed. Compassion Fatigue: Compassion Fatigue:

Coping with Secondary Traumatic Coping with Secondary Traumatic Stress in Those Who Treat the Stress in Those Who Treat the Traumatized.Traumatized. London: Brunner- London: Brunner-Routledge, 1995Routledge, 1995

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Zuker A. Dissatisfaction with medical Zuker A. Dissatisfaction with medical practice. practice. N Engl J Med.N Engl J Med. 350:69-75, 2004. 350:69-75, 2004.


Eric Cassell. Eric Cassell. The Nature of Suffering The Nature of Suffering and Goals of Medicine.and Goals of Medicine. New York: New York: Oxford Press. 2004.Oxford Press. 2004.

James Hallenbeck. James Hallenbeck. Palliative Care Palliative Care Perspectives.Perspectives. New York: Oxford New York: Oxford University Presss, 2003.University Presss, 2003.

Nouwen H. Nouwen H. The Wounded HealerThe Wounded Healer,, Garden City, NY. Doubleday, 1972.Garden City, NY. Doubleday, 1972.

Ferrell BR, Coyle N. Ferrell BR, Coyle N. The Nature of The Nature of Suffering and the Goals of Nursing.Suffering and the Goals of Nursing. Oxford University Press, 2008.Oxford University Press, 2008.

Suggested ReadingsSuggested Readings Ken Wilber, Grace and Grit: Ken Wilber, Grace and Grit: Spirituality Spirituality

and Healing in the Life and Death of and Healing in the Life and Death of Treya Killam WilberTreya Killam Wilber,, Boston, Shambhala, Boston, Shambhala, 2000.2000.

Wallace Stegner, Wallace Stegner, Crossing to SafetyCrossing to Safety, , 1987, Modern Library, 2002.1987, Modern Library, 2002.

Wallace Stegner, Wallace Stegner, All the Little Live All the Little Live ThingsThings, Penguin Books, 1967, Penguin Books, 1967

Jean Vanier, Jean Vanier, Becoming HumanBecoming Human, Paulist , Paulist Press, 1999.Press, 1999.

Michael Kearney, Michael Kearney, Mortally WoundedMortally Wounded. New . New York: Simon and Schuster, 1996York: Simon and Schuster, 1996

Suggested ReadingsSuggested Readings Michael J Fox, Michael J Fox, Lucky Man: A Memoir,Lucky Man: A Memoir,

Hyperion, 2003.Hyperion, 2003. Michael J Fox, Michael J Fox, Always Looking Up: Always Looking Up:

The Adventures of an Incurable The Adventures of an Incurable Optimist,Optimist, Hyperion, 2009. Hyperion, 2009.

Jean Shinoda Bolen, Jean Shinoda Bolen, Close to the Close to the BoneBone, New York: Touchstone, 1996., New York: Touchstone, 1996.

Christine Longaker, Christine Longaker, Facing Death and Facing Death and Finding Hope: A Guide to the Finding Hope: A Guide to the Emotional and Spiritual Care of the Emotional and Spiritual Care of the DyingDying,, New York: Doubleday, 1997 New York: Doubleday, 1997

David Kuhl, David Kuhl, What Dying People What Dying People Want,Want, New York: PublicAffairs, 2002. New York: PublicAffairs, 2002.

Suggested ReadingSuggested Reading

Reynolds Price, Reynolds Price, A Whole New Life: An A Whole New Life: An Illness and a HealingIllness and a Healing,, Schribner, 2003. Schribner, 2003.

Christopher Reeves, Christopher Reeves, Still MeStill Me, Ballantine , Ballantine Books, 1999.Books, 1999.

Christopher Reeves, Christopher Reeves, Nothing Is Nothing Is Impossible,Impossible, Ballantine Books, 2004. Ballantine Books, 2004.

Martha Weinman Lear, Martha Weinman Lear, Heartsounds,Heartsounds, New York: Simon and Schuster, 1980.New York: Simon and Schuster, 1980.


Morton Kondrake. Morton Kondrake. Saving MillySaving Milly, New , New York: Ballantine Books, 2001.York: Ballantine Books, 2001.

Reeve Lindbergh. Reeve Lindbergh. No More Words: A No More Words: A Journal of My MotherJournal of My Mother, Anne Morrow , Anne Morrow Lindbergh,Lindbergh, New York: Simon and New York: Simon and Schuster, 2001.Schuster, 2001.

William Bridges. William Bridges. The Way of The Way of Transition: Embracing Life’s Most Transition: Embracing Life’s Most Difficult MomentsDifficult Moments. Cambridge, MA, . Cambridge, MA, Perseus Publishing, 2001.Perseus Publishing, 2001.


Ram Dass, Ram Dass, Still Here: Embracing Aging, Still Here: Embracing Aging, Changing, and DyingChanging, and Dying,, Riverhead Trade, Riverhead Trade, 2001.2001.

Viktor Frankl, Viktor Frankl, Man’s Search for Man’s Search for MeaningMeaning,, Pocket Publishers, 1971 Pocket Publishers, 1971

Ira Byock. Ira Byock. Dying Well: Peace and Dying Well: Peace and Possibilities at the End of LifePossibilities at the End of Life.. New New York: Riverhead Books, 1997.York: Riverhead Books, 1997.

Kotter J. Kotter J. Leading ChangeLeading Change,, Harvard Harvard Business School Press, 1996Business School Press, 1996

Suggested ReadingSuggested Reading Bill Bazan. Bill Bazan. Medicine In Search of Medicine In Search of

Meaning: A Spiritual Journey for Meaning: A Spiritual Journey for PhysiciansPhysicians,, Caritas Communications, Caritas Communications, 1999.1999.

Kirk Byron Jones. Kirk Byron Jones. Rest in the Storm: Self-Rest in the Storm: Self-care Strategies for Clergy and Other care Strategies for Clergy and Other CaregiversCaregivers Judson Press, 2001 Judson Press, 2001

The Dalai Lama. The Dalai Lama. The Art of HappinessThe Art of Happiness,, Riverhead Books, 1998.Riverhead Books, 1998.

William Bridges. William Bridges. The Way of Transitions: The Way of Transitions: Embracing Life’s Most Difficult Embracing Life’s Most Difficult MomentsMoments,, Perseus Publishing, 2001. Perseus Publishing, 2001.


Kubler-Ross E. Death: Kubler-Ross E. Death: The Final Stage of The Final Stage of Growth,Growth, New York: Touchstone, 1975. New York: Touchstone, 1975.

Kabat-Zinn J. Kabat-Zinn J. Wherever You Go, There Wherever You Go, There You Are.You Are. New York: Hyperion, 1994. New York: Hyperion, 1994.

Santorelli S. Santorelli S. Heal Thy Self: Lessons on Heal Thy Self: Lessons on Mindfulness in MedicineMindfulness in Medicine,, New York: Bell New York: Bell Tower, 1999.Tower, 1999.

Arthur W. Frank. Arthur W. Frank. The Wounded The Wounded Storyteller: Body, Illness, and EthicsStoryteller: Body, Illness, and Ethics. . University of Chicago Press, 1997.University of Chicago Press, 1997.


Brian Sibley. C.S. Brian Sibley. C.S. Lewis through the Lewis through the Shadowlands: The Story of His Life Shadowlands: The Story of His Life with Joy Davidmanwith Joy Davidman,, Grand Rapids: Spire, Grand Rapids: Spire, 1999.1999.

Henri J.M. Nouwen. Henri J.M. Nouwen. Our Greatest Gift: A Our Greatest Gift: A Meditation on Dying and CaringMeditation on Dying and Caring,, San San Francisco: HarperCollins, 1994.Francisco: HarperCollins, 1994.

Harold S. Kushner. Harold S. Kushner. The Lord is My The Lord is My Shepherd: Healing Wisdom of the Shepherd: Healing Wisdom of the Twenty-Third PsalmTwenty-Third Psalm,, New York: Anchor New York: Anchor Books, 2003.Books, 2003.

Suggested ReadingSuggested Reading Daniel Sulmasy. Daniel Sulmasy. The Healer’s Calling: A The Healer’s Calling: A

Spirituality for Physicians and Other Health Spirituality for Physicians and Other Health Care ProfessionalsCare Professionals.. Paulist Press, New York, Paulist Press, New York, 19971997

Daniel Sulmasy. Daniel Sulmasy. The Rebirth of the Clinic: An The Rebirth of the Clinic: An Introduction to Spirituality in Health CareIntroduction to Spirituality in Health Care, , Georgetown University Press, 2006Georgetown University Press, 2006

Arthur W. Frank. Arthur W. Frank. The Wounded Storyteller: The Wounded Storyteller: Body, Illness, and EthicsBody, Illness, and Ethics. Chicago, University . Chicago, University of Chicago Press, 1995.of Chicago Press, 1995.

Milton Lewis. Milton Lewis. Medicine and Care of the Medicine and Care of the Dying: A Modern HistoryDying: A Modern History. Oxford University . Oxford University Press.Press. 2006 2006

Suggested ReadingsSuggested Readings {Risking Everything},{Risking Everything}, Roger Housden Roger Housden

(ed), New York, Harmony Books, 2003(ed), New York, Harmony Books, 2003 Jane Kenyon. Jane Kenyon. Let Evening Come (Poems),Let Evening Come (Poems),

Saint Paul: Graywolf Press, 1990.Saint Paul: Graywolf Press, 1990. Jane Kenyon. Jane Kenyon. Otherwise: New and Otherwise: New and

Selected Poems.Selected Poems. Saint Paul: Graywolf Saint Paul: Graywolf Press, 1996.Press, 1996.

Donald Hall. Donald Hall. Without. (Poems),Without. (Poems), New York: New York: Mariner Books, 1998.Mariner Books, 1998.

Mary Oliver. Mary Oliver. West Wind (Poems and West Wind (Poems and Prose Poems),Prose Poems), New York: Mariner Books, New York: Mariner Books, 1997.1997.

WebsitesWebsites

www.commonweal.org/ishi/www.commonweal.org/ishi/ www.zenhospice.orgwww.zenhospice.org www.hospitalchaplain.comwww.hospitalchaplain.com www.erperc.mcw.eduwww.erperc.mcw.edu

http://www.commonweal.org/ishi/

http://www.hospitalchaplain.com/

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