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© EPEC Project, 2003
Permission to reproduce for educational purposes granted
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Module 4:=
Pain
Management
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E
P
E
C
P
E
C
Professional Self Care
Module=
13
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Learning Objectives
•Recognize that stress impacts the physician providing end of life care
•Provide a framework to understand the sources of stress and their loci of expression
=
•Identify appropriate coping strategies to deal with stress
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INTRODUCTION
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Self-care=
is
a core competency for physicians. Without <=
span
style=3D'font-family:Arial;font-size:83%;text-shadow:auto;color:white;
mso-color-index:0'>this skill, working in end of life care will not be =
able
to be sustained.
<=
/span>
Caring for the dying is hard work. Working to teach =
=
others about palliative care is also challenging.=
3;
What do physicians do to avoid having their professional life become burdensome?
=
How do physicians revitalize themselves when others =
=
are drained?
How do they avoid exhaustion and continue to serve?&=
#13;
Sources of stress
Sources of stress
Failure is not something that physicians value as a group. Even=
=
admission to the profession requires intense
competition, achieveme=
nt,
and succeeding where others have not.
For some, the threat of failure is the whip that spu=
rs
personal achieveme=
nt.
Some have observed that same whip applied in the service of education.
Examples are the faculty response to a student physi=
cian
who inadequately answers a
question about pathophysiology or the failure of a resident to list a sufficiently extensi=
ve
differential diagnosis=
at
morning report.
Many observed that the relu=
ctance
to tell a patient that they will die despite of all=
of
the medical advances about which they have heard is on=
e more
way to avoid a personal
sense of failure.
Institutional resources may be as important as cultu=
re.
Identifying coping
strategies
There are a variety of ways of coping with the stres=
s of
caring for patients =
and
their families at the end of life that are best carried out at the organizational level.
Some suggest that the single most important way to c=
ope
with patient and job related
stress is to seek the social support of =
others. To take care of patients as part of a networ=
k of
caring and reciprocal
relationships with other health care pro=
fessionals
creates a sense of belonging and a sense of professional accomplishment that transcends ones
individual self. =
3;This can happen on an individual basis, or in schedu=
led sessions. One physician described including a nurse =
in
every difficult encounter.
“It leads to reflection and an additional =
source of support&n=
bsp;
and for the patient, particularly when I can’t =
be there.”
<=
span
style=3D'font-family:Arial;font-size:83%;text-shadow:auto;color:white;
mso-color-index:0'>Regularly scheduled patient-care conferences can per=
mit
the discussion of care of
individual patients with others, including the =
stress that it brings.
Simply sharing observations in the conte=
xt
of a case conference can be a
clear benefit. The interdisciplinary team meeting that <=
span
style=3D'position:absolute;top:33.25%;left:7.67%;width:100.93%;height:4.5%=
'>Medicare-certified hospice programs are required to =
have
serve this function.
=
Some participants called these “de-griefing=
221;
sessions after a particula=
rly
difficult case and bad/troubling death. Several noted =
that it helps to constructively talk about problems
while commending each other f=
or
doing our best. As long as the intention=
is
constructive, issues that could have been done differently, or should prepare to do differently in
future similar circumstances, can
safely be discussed.
Open, trusting sessions like this help bring closure,
reinforce a team spirit, and di=
rect
attention to the future.
Consequences of copi=
ng
well
=
Developing good coping skills leads to professional =
and personal well-being.
Those who are happy in the work find they contrast t=
heir
attitude with that of t=
heir
colleagues:
=
“While my partners th=
ink
that working with the dying is
depressing, I fi=
nd it
rewarding and exciting to help people =
live as well as
possible and then die better than anyone =
=
thought
possible”.
Feeling
competent and confident in working with the dying can shape our own attitude toward death and dying.
People who do stressful work and are professionally
satisfied score hig=
her
on skills of inner directedness, self-actualizing value, spontaneity, self-regard, self-acceptance,
acceptance of
aggression, and capacity for intimate contact. Another way of characterizing the sane qualities has been termed=
the
‘hardy
personality’. The Hardy Personalit=
y is a personality characteristic that is characterized by:<=
/span>
=
A
sense of commitment to the work (as opposed to alienation) reflecting
a curiosity about, and a sense of meaningfulness of life
Control (as opposed to powerlessness) when reflecting a
belief that one has the power to influence the
course of relevant events rather than being powerles=
s to
affect the course
Challenge
(as opposed to threat) epitomizing the expectation that =
<=
span
style=3D'font-family:Arial;font-size:83%;text-shadow:auto;color:yellow'>it is
normal for life to change and for development to be =
stimulated
Physicians can find end-of-life care to be
professionally rewarding.
Self-care is critically important if this is to be
maintained.
Key points
Self-care is a core competency of end-of-life care.&=
#13;
Ba=
umrucker
SJ. Palliative care, burnout, and the pursuit of happiness. =
Am=
erican
Journal of Hospice & Palliative Care 2002;19: 154-6.
Me=
ier
DE, Back AL, Morrison RL. The Inner Life of Physicians and the Ca=
re of
the Seriously Ill. JAMA 2001;286:3007-14.
No=
vack
DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Ca=
librating
the physician. Personal awareness and effective patient care. JA=
MA
1997;278:502-9.
Rabow MW, McPhee SJ. Doctoring to Heal: fostering well-being among ph=
ysicians
through personal reflection. Western Journal of Medicine 200 l;=
174:66-9.
Redinbaugh Em, Sullivan AM, Block =
Sd,
Gadmer NM, Lakona M, Mitchell AM, Seltzer D, Wolford J, Arn=
old
RM. Doctors emtional reactions to recent de=
ath of
a patient: A cross sectional study of hospital doctors. BMJ =
20=
03;327:185.
End of Module 13:
Professional Care
Review Fast Facts
Complete Module 13 Post Assessment
‹header›
‹date/time&=
#8250;
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1. Feelings of grief are a natur=
al
response for the medical professional in caring for patients who are at
Life’s End. It is important to develop a healthy response to stresses
secondary to loss and the tragedies that can occur at Life’s End.=
3;2.
“Burn-out” resulting from fatigue, multiple losses, and unreso=
lved
emotional distress can occur in the emotionally charged setting of End-of-=
Life
care. The palliative-care approach assists the provider with feelings of g=
rief
and loss by offering the support of an interdisciplinary team, each of who=
se members
brings unique strengths and abilities. The team approach recognizes unique
strengths and abilities; accepts individual limits; and fosters requesting=
and
providing assistance, thus relieving the provider from bearing loss
alone.
3. Palliative care cushions the provider’s sense of loss =
and
grief by reframing treatment success.
Palliative care reframes
“failure to cure” at Life’s End as success in fostering =
holistic
healing and enabling patients to live life fully.
4. The medical provi=
der
needs to self-monitor for the depression, anger, and resentment that can
result from unattended grief. Ask:
“Do I still enjoy my work? Are
there patients or tasks that I avoid or dread? “Do I attend to my
personal health?” Self-care includes:
• Recuperation (rest and adequate sleep)
• Restoration (nutrition)
• Rejuvenation (exercise)
• Relaxation (taking all vacation time every year and regular&#=
13;
time away)
• Relationships (personal and professional)
• Reflection (religion and spirituality)
• Self-referral for concerns about physical and emotional health or
substance abuse
5. Foster mentor relationships; seek mentors and be a
mentor. Even the most skilled medical provider needs someone with whom to
discuss problems, feelings, and emotions and from whom
to seek guidance.
6. Self-care is an important part of being a mature and effective healthca=
re provider.
Dying persons, including dying medical professionals, do not say, “I=
wish
I had spent more time at the office.”
There are two themes that emerge=
when
physicians discuss self-care. The first is the need to recognize the stress
and how alone individuals feel at times, especially initially when working=
in
palliative and end-of-life care.
Second, is the need to value the
professional rewards that makes it worthwhile to want to cope with the
stress.
Why are We Doing This?
Understanding our own needs can be stimulated by reflecting on answers to =
a few
questions. What gives us a sense of personal meaning in life? What do we v=
aluse?
What leads to our onw quality of life? Is it our work; our family; our fri=
ends;
our inner life?Physicians fulfill a special rol=
e within
our society. While they are given many privileges and rewards, they also c=
arry
serious responsibilities. Physicians are expected to be healers, available=
to
others whenever a crisis occurs or a medical need arises. They are expecte=
d to
have unfailing expertise and competence, to be compassionate and concerned,
and to provide universally successful care in a cost-effective manner. Such
idealized expectations emanate from patients, from families, from society
(including payers and regulatory and accreditation agencies), and from wit=
hin
the profession of medicine itself. Self-imposed expectations inhere in the
institutions of medicine -- medical colleges, clinics, hospitals, professi=
onal
associations, and collegial relationships -- and are internalized by stude=
nts
of medicine as they are socialized to become practicing professionals. The=
se
expectations become a part of how physicians define themselves.
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