Avoiding 'compassion fatigue' in palliative, end-of-life care
WASHINGTON — In difficult conversations with patients and their families regarding palliative and end-of-life care, it is important for physicians to understand the effects such discussions can have on their own state of mind, and any potential effects it may have on their practice, according to a presentation given at the American College of Physicians Internal Medicine Meeting.
According to Janet Abrahm, MD, FACP, of the division of adult palliative care at Harvard Medical School, physicians who often discuss end-of-life care with patients and their families can suffer from “compassion fatigue,” which can stem from the common gap between what is hoped for and reality. She added that sometimes patients and their families can accuse physicians of “taking away” their hope, which can have a significant effect on their professional identity.
Janet Abrahm, MD, FACP
“Sometimes when a patient says something like, ‘You can’t give up on me, doctor,’ that hits your identity as a healer, that makes you start reeling,” Abrahm said. “And if you feel like you’re reeling, I want you to recognize that’s a hit on your identity, and you need to stop. You might need to pretend your beeper went off, and go out on the roof for a second, and regather yourself, because it can affect your judgement, and it can affect the things you offer the patient.”
Abrahm said compassion fatigue can affect seasoned clinicians, and can produce a sense of failure and frustration as the patient’s illness progresses. It can be accompanied by stress-related medical problems, anxiety and depression, substance abuse and family disruption.
In many cases, physicians have problems recognizing their own grief, she added.
“If you put theses worries into a closet and you never open that closet, you are going to get compassion fatigue,” Abrahm said. “I certainly did, and I had to recover from that.”
Compassion fatigue can lead to suboptimal patient care, due to detachment and a depersonalizing of the patient, according to Abrahm. Physicians can sometimes doubt themselves, questioning how they can care for a patient if it is too painful to even sit and talk with them or their family.
To combat this, Abrahm suggested starting an office project, specifically identifying patients with 1 to 2 years to live, putting them on a palliative care list, finding their healthcare proxies and ensuring their families understand their loved one’s disease is incurable, making the prognosis clear and supporting family members in this distress.
If you don’t talk about this stuff, you’re going to feel like you’ve failed them,” Abrahm said. “If you routinely talk with people about their hopes and fears, and you get professional satisfaction from dealing with those hopes and fears, as they get sicker and their lives wind down, you’ll protect yourself from compassion fatigue.”
Abrahm also stressed that physicians, just like patients and their families, should “never worry alone.”
“Encourage a culture of debriefing, and share the care of the toughest patients,” Abrahm said. “Grieve together. Send a condolence card from the office. Identify sources of support, and attend or sponsor a remembrance service. Maybe decide that the office is going to go, or the office is going to send flowers. Depending on the size of your office, these are all things one can do to make it through the process.” – by Jason Laday
Disclosure: Abrahm reports receiving royalties from Up-to-Date and Johns Hopkins University Press, and expense reimbursement and honoraria from Knowledge to Practice.
Abrahm J. Palliative and end of life care: Communication challenges and community partners. Presented at the American College of Physicians Internal Medicine Meeting, May 5 to 7, 2016; Washington, D.C.