First Draft version of Presentation for 11/19/2009 - KU Palliative Care Fellowship Lecture Series. Uploaded to show the evolution of creating a slide presentation

1. Stress and the Professional Caregiver Christian Sinclair, MD, FAAHPM Kansas City Hospice & Palliative Care Nov 19, 2009

2. Objectives

3. Overview 25% of palliative care staff report symptoms Indicates psychiatric morbidity and burnout Lower than that of other specialties Like oncology

4. Definitions Stress Relationship between employee and work environment Demands from the work environment exceed the employee’s ability to cope with or control them Burnout Progressive loss if idealism, energy and purpose experienced by people in the helping professions as a result of the conditions of their work Related to our need to believe in meaningful work/life Chronic interpersonal stressors Exhaustion Cynicism/detachment Lack of accomplishment

5. Signs and Symptoms of Burnout Fatigue Physical exhaustion Emotional exhaustion Headaches GI disturances Weight loss Sleeplessness Depression Boredom Frustration Low morale Job turnover Impaired job performance (decreased empathy, increased absenteeism

6. Maslach Burnout as a psychological syndrome Exhaustion – individual Cynicism – relationship Lack of accomlishment – self-eval Not due to an individuals disposition

7. Maslach Burnout associated with: Demographics Single Younger No gender diff Personal char Neuroticism Low hardiness Lo self-esteem Strongest association with job characteristics Chronically difficult job demands Imbalance of high demands, low reources Presence of conflict (people, roles, values

8. Kumar et al - psychiatrists Predisposing Personality Work cond Precipitating Violence with pts Suicidal patients On call duties Perpetuating How one perceives and responds to stress

9. Is burnout just depression Overlapping constructs If you have severe burnout higher risk of major depressive disorder If you have major depressive disorder higher risk of burnout

10. Compassion Fatigue Secondary traumatic stress disorder Identical to post-traumatic stress disorder Except the trauma happened to someone else Bystander effect No energy for it anymore Emptied, no

11. Countertransference Alchemical reaction between patient and caregiver at themost vulnerable time in ones life – thru the experience both can be transformed Whole person care The social brain is wired to help others in distress

12. Study 5 -age UK study of phsyicians - #5 Burnout associated with being under age 55 Increased job satisfaction with older age Emotional sensitivity increases with age-37-38 Married with children mixed results

13. Hardiness 42-43-44 Sense of commitmment, control and challenge Helps perception, interpretation, successful handling of stressful events Prevetns excessive arousal Oncology docs and nurses 46

14. resilience Not avoidance of stress But stress that allows for self-confidence thru mastery and appropriate responsibility Hardiness versus coherence

15. Emotional Sensitivity Hospice Nurses 38 Extroverted Empathic Trusting Open Expressive Insightful Group oriented Cautious with new ideas Potentially naïve in dealing with those more astute Lacking objectivity

16. Genetics 5-HTT short alleles

17. Social Support Early identified as important Similar to critical nurses Buffer to stress in workplace and assoicated with optimism Lack of social support predicted anxiety and psychosomatic complaints

18. Attachment Style 84 UK nurses Secure Preoccupied Fearful Dismissing

19. Stressful life events

20. MD comparisons Htable 16.2 Deporsonilzation associated with work overload

21. Religiosity, Spirituality, Meaning making Hospice staff more deeply religious (1984) Religious associated with decr risk of burnout in onc staff (2000) 44 230 NZ MD correlation between religion and vicarious traumitzation higher compassion fatigue but a negative one with spirituality and burnout 11

22. Engagement v. Burnout Workload – associated with deprsonalization Control – performing without training/outside epxertise Reward – Intrinsic and extrensic Money, care, touch, stories, love Lo ,though I walk through the valley of the shadow of death, it is never my turn Community – group v. team Fairness Values – individual moral agent, professional role and team Engagement: nrg, involvement, efficiency Compassion satisfaction

23. Emotional Work Variables Closenss vs. distance Controlled closeness Strategies: Patient rotation Choosing when and where closeness Rational reflection of internal process Concentrating on one’s own role Anticipating patient death Maintaining appropriate composure “No, within love” avoid being destroyed in the process of caring

24. Inability to live up to one’s own standards Good or better death haunt our field Expectation of an unattainable ideal No pain therapy, symptom control support in psycho social and spiritual dimension can take the horror away from death. Avoid dramatisation of ideals and practice modesty and humbleness

25. Death acuity/volume Rarely studied

26. Evidence Based Interventions Few studies Poorly powered Mindfulness fully present without judgement Narrative driven workshops Dot theory Abcd of dignity conserving care Attitude, behavior, compassion dialogue

27. Bibliography Vachon MLS. The stress of profesisonal caregivers. Oxford Textbook of Palliative Medicine 3rd edition (2004). p992-1004. Vachon MLS, Muller M. Burnout and symptoms of stress in staff working in palliative care. Oxford handbook of Psychoatry in Palliative Care (2009). p236-264.