Category Archives: Policy

Is Compassion Fatigue the Adversary of Compassionate Pain Management?

Ann Quinlan-Colwell, PhD, RNC, AHNBC, DAAPM

In the last newsletter, compassion was discussed as the possible ghost of pain management.  Intrinsic in that possible relationship is the potential ingredient known as compassion fatigue which is described by Sinclair and colleagues (2017) as “a work-related stress response in healthcare providers that is considered a ‘cost of caring’ and a key contributor to the loss of compassion in healthcare.”   The stress response involved in compassion fatigue is believed to evolve while caring for patients, clinicians repeatedly experience, in a secondary manner, the traumatic events and/or suffering of patients.  Although, there is no identified theoretical basis, empirical validation or measurement, there is general consensus that compassion fatigue is real and does clinically exist internationally (Sinclair et al, 2017).  It is certain that for a clinician to experience compassion fatigue, the clinician must first have compassion and experience compassion with patients. Ironically, the terminal result of compassion fatigue is that such an originally compassionate caregiver, no longer feels empathic or nurturing toward others, and no longer feels energetic or enthusiastic about the profession once so loved.

The term was first used in 1992 by a nurse educator, C. Joinson, who coined the term compassion fatigue to describe the burnout she observed among healthcare providers.  Today, although compassion fatigue is at times considered a branch of burnout (Sabo, 2011), it is generally considered different from burnout (Lanier, 2017).  In 1995, Dr. Charles Figley (Tulane University) described compassion fatigue occurring as the result of secondary traumatic stress occurring among caregivers when caring for people who are suffering as a result of a traumatic event.  He described the secondary traumatic stress/compassion fatigue as being similar to the post traumatic stress disorder (PTSD) experienced by the traumatized person.  In fact, the symptoms attributed to PTSD and compassion fatigue are remarkably similar (See Table 1). 

Table 1

Post Traumatic Stress Disorder Symptoms

Compassion Fatigue Symptoms

   

Upsetting thoughts

Intrusive thoughts

Irritable

Irritability

Flashbacks

Traumatic memories

Upset by memories

Anger

Trouble sleeping

Insomnia or difficulty sleeping

Nightmares

Nightmares

Concentration difficulties

Difficulty concentrating or focusing

Jumpy

Startle reactions

Overly careful

Hypervigilant

Emotional distance

Patient/client avoidance

Overly careful

Self-doubt and questioning self

Loss of interest

Depressed mood

Avoid activities

Isolating self

Memory difficulties

 

Taken from:

Foa, Johnson, Feeny, & Treadwell, (2001).

Taken from:

Fidley, 1995; Fidley, 2002; Sabo, 2011; Sinclair, et al, 2017

Figley defined compassion fatigue “as a state of tension and preoccupation with the traumatized patients by re-experiencing the traumatic events, avoidance/numbing of reminders persistent arousal (e.g. anxiety) associated with the patients … a function of bearing witness to the suffering of others”  (Figley, 2002, p. 1435).  The Compassion Fatigue Self Test of Psychotherapists was developed by Figley and later adapted by others with one version adapted with the permission of Figley available via http://www.community-networks.ca/wp-content/uploads/2015/07/Self-Assessment-Tools-Compassion-Fatigue-Feb-22-2010.pdf   In his Compassion Stress and Fatigue Model, Figley (1995, 1997, 2002) described ten variables which combine to result in compassion fatigue and which can be modified to avoid or mediate the development or experience.  The ten variables are listed in Table 2 along with a brief description of each one.

Table 2 Variables of Figley Compassion Stress and Fatigue Model

Model Variable

Description  of variable

Empathic ability

The ability to appreciate pain in another person.

Empathic concern

The impetus to respond to the pain of another person.

Exposure to the patient

Directly being exposed to and experiencing the emotional energy of the suffering person.

Empathic Response

Using insight to share the perspective of the suffering person in an effort to ease the pain and suffering of the person.

Compassion Stress

The effect of the energy expending during the empathic response which can result in negative effects on the well- being of the caregiver.

Sense of Achievement

The satisfaction with compassionate efforts that are experienced by the caregiver who has clear boundaries and concepts of responsibility. 

This variable is protective against compassion fatigue and promotes compassion satisfaction.

Disengagement

The ability, between encounters, to put space between self and the suffering patient and let go of the qualities associated with the suffering experience.  It also involves the clinician in fully engaging in his or her own life. 

When utilized this variable also is protective against compassion fatigue. 

Prolonged Exposure

Over time the persistent belief of responsibility for the person and the associated suffering.  The more intense the exposure with limited interruptions the greater the compassion fatigue.

Traumatic Recollections

These are memories of other experiences or the experiences of other patients which trigger emotional and stressful reactions (i.e. anxiety or depression).

Life Disruption

The unanticipated events that necessitate change in routine or schedule which normally occur in life.  However, when combined with the other variables, the likelihood of compassion fatigue developing increases.

 

Taken from: Figley, 2002, pp. 1436 – 1438.

Although the concept descriptor, compassion fatigue, was only coined 25 years ago, compassion fatigue is now considered an occupational hazard of health care workers (Mathieu, 2012).  Estimates of prevalence range as high as 40% in Intensive Care Units (van Mol, Kompanje, Benoit, Bakker, & Nijkamp, 2015).  Not only is it a general occupational hazard, but among clinicians who strive not only to do well, but to at all times to do their best,  Figley noted it is a “disorder that affects those who do their work well” (Figley, 1995, p. 5).  Traumatologist Eric Gentry proposed that many who enter caregiving professions suffer from compassion fatigued prior to even starting their profession because they previously learned to care for others rather than learning to care for self (Lanier, 2017).

Equipped with this knowledge, it seems reasonable to conclude there is an ethical responsibility to educate those who are at greatest risk (i.e. all clinicians) to be able to empathically and compassionately care for patients while promoting compassionate satisfaction and preventing compassion fatigue.  As a first step in addressing this responsibility, the next segment of this series will address the concept of self-compassion and the final segment will discuss restoring compassion in the work of pain management.  Now that you have read about the dilemma, hopefully, you will return to read about viable resolutions.

 

References

Abendroth, M., (Jan 31, 2011) “Overview and Summary: Compassion Fatigue: Caregivers at Risk” OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 1, Overview and Summary. DOI: 10.3912/OJIN.Vol16No01OS01

Figley, C. (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York, NY: Brunner-Routledge.

Figley, C.R. (1997). Burnout in families: The systemic costs of caring. Boca Raton: CRC Press

Figley, C. (2002). Compassion fatigue: Psychotherapists’ chronic lack of self care. Psychotherapy in Practice, 58(11), 1433-1441.

Foa, E. B., Johnson, K. M., Feeny, N. C., & Treadwell, K. R. (2001). The Child PTSD Symptom Scale: A preliminary examination of its psychometric properties. Journal of Clinical Child Psychology, 30(3), 376-384.

Gentry, J. E..  Baranowsky, A. & Dunning,   (1997).  Compassion Fatigue Article: Accelerated Recovery Program (ARP) for compassion fatigue.  Traumatology Institute. Online Training for Trauma Professionals.

Joinson, C. (1992). Coping with compassion fatigue. Nursing 22(4), 116-122.

Lanier, J. (2017).  Running on empty: Compassion fatigue in nurses and non-professional caregivers. The Bulletin Indiana State Nurses Association, 44(1), 10-14.

Mathieu, F. (2012). The Compassion Fatigue Workbook. NY, NY: Taylor and Francis Group.

Sabo, B., (Jan 31, 2011) “Reflecting on the Concept of Compassion Fatigue” OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 1, Manuscript 1. DOI: 10.3912/OJIN.Vol16No01Man01

Sinclair, S., Raffin-Bouchal, S., Venturato, L., Mijovic-Kondejewski, J., & Smith-MacDonald, L. (2017). Compassion fatigue: A meta-narrative review of the healthcare literature. International Journal of Nursing Studies, 69, 9-24.

Todaro-Franceschi V.  (2013). Compassion Fatigue and Burnout in Nursing New York, NY: Springer Publishing Company.  ISBN: 978-0826109774

van Mol, M. M., Kompanje, E. J., Benoit, D. D., Bakker, J., & Nijkamp, M. D. (2015). The prevalence of compassion fatigue and burnout among healthcare professionals in intensive care units: a systematic review. PloS one, 10(8), e0136955.

President’s Message January 2017 – Mordecai Potash, MD

It is my great pleasure to author my first column as President of the Southern Pain Society. In trying to find some inspiration for this column, I went through my New York Times’ collection of articles about chronic pain. I have long been a print and then digital subscriber to the Times, and now have amassed a collection its articles about chronic pain, pain management, and palliative care issues (with thanks to my father-in-law, who dutifully sends to me any article that escaped my eye).

Looking at these articles chronologically, it shows the great arc of change that our field has been through during our professional careers. From one practice standard and swinging to another – pain management as a field and as a professional practice has experienced marked changes and intense scrutiny that few fields of medicine have undergone over the last thirty years.

Just looking at the headlines (not even the articles themselves) will give you a good taste of this:

  • August 26, 1985 – “Helping Families Deal With Chronic Pain”
  • March 28, 1993 – “Patients in Pain Find Relief, Not Addiction, in Narcotics”
  • July 29, 2001 – “The Alchemy of OxyContin”
  • December 21, 2001 – “Few States Track Prescriptions As Way to Prevent Overdoses”
  • November 25, 2003 – “The Delicate Balance Of Pain and Addiction”
  • October 19, 2004 “Doctors Behind Bars: Treating Pain Is Now Risky Business”
  • May 30, 2006 – “Doctors Struggle to Treat Mysterious and Unbearable Pain”
  • March 27, 2007 – “Trafficker or Healer? And Who’s the Victim?”
  • June 17, 2007 – “Doctor or Drug Pusher”
  • August 29, 2007 – “A Surplus of Treatment Options, Few of Them Good”
  • May 13, 2008 – “Back Pain Eludes Perfect Solutions”
  • November 05, 2009 – “Treating the Pain Epidemic”
  • April 09, 2012 – “Tightening the Lid On Pain Prescriptions”
  • May 21, 2016 – “Prescription Dip Seen as Advance in Opioid Battle”
  • March 16, 2016 – “New Standards for Painkillers Aim to Stem Overdose Deaths “
  • November 23, 2016 – “If the Doctor Orders Marijuana, Will Insurers Pay?”
  • December 29, 2016 – “Ethics and Pain: It’s Complicated”

See what I mean? From recognizing that many were languishing unnecessarily due to pain; to beginning to recognize the societal trade-offs that would stem from aggressive pain management; to re-evaluating the legitimacy of providers who treat patients’ pain zestfully; to recognizing that effective pain management treatments are often elusive or expensive (or both); to trying to craft new guidelines to stem prescription abuse; to grappling with the impact of the medical cannabis movement; and to finally recognizing that our field is inherently complicated and perennially chock-full of contradictions.

Many of these articles have the term “double-edge sword” in their text, either as an interview quote or as a journalistic conclusion. This term does capture the dichotomy of our work – the very treatments that can be nearly life-saving for one of our patients can be ineffective for another, or even life-destroying. This dichotomy is true whether our treatments include extended release opiates, nerve blocks, rhyzotomies, kyphoplasties, spinal stimulators, infusion pumps, mindfulness exercises, or any other treatment that we render.

I personally know patients that have had such positive responses to each of these treatments, the word ‘miracle’ tumbles out repeatedly as they describe their response. I also know patients that would describe each of these treatments as having ruined their lives, leaving them even more disabled and embittered than prior to treatment (well, truth be told, I don’t know anyone who would describe ‘mindfulness’ as ruinous – just a hippy-born, navel-gazing, fantastic waste of time).

As we start 2017, the arc of change continues. Many state legislatures and healthcare payers / insurers are considering tremendous regulatory changes in light of both the CDC’s recommendations on opiates for the treatment of chronic pain and the nation’s changing attitudes towards the use of cannabis for the treatment of pain. Several recent articles have suggested a “swap” of chronic opiates for chronic cannabis – suggesting that this would lead to less societal pain such as traffic accidents and overdose deaths [1]. Even as some authors suggest these changes, disturbing reports about dramatic increases in traffic accidents, accidental childhood exposure, intense side effects, and – yes – overdose deaths are appearing in medical [2] and legal reports [3].

I am not “poo-pooing” medical marijuana. Rather – if there is anything the last 30+ years has demonstrated to us over and over again – it is that there are no easy answers in pain management. An approach that may work wonders for one patient may fail miserably in another. What remains the truest ‘answer’ is the ethos that I have seen demonstrated over and over again from our colleagues, in our newsletters, and at our conferences. We treat our patients with zealous compassion, encouraging that they deserve to live a life free of intense daily suffering, and advocating to institutions about preserving and enhancing treatment options for people with chronic pain.

I guarantee you that 2017 will bring new challenges to this ethos. But I also guarantee you that we have together faced similar challenges in the past and that our organization will continue to educate and promote our highest healing ideals.

REFERENCES

[1] Eric Sarlin. Study Links Medical Marijuana Dispensaries to Reduced Mortality From Opioid Overdose. NIDA Notes, published 05/17/2016 and accessed at  https://www.drugabuse.gov/news-events/nida-notes/2016/05/study-links-medical-marijuana-dispensaries-to-reduced-mortality-opioid-overdose
[2] Howard S. Kim, et al. Cyclic Vomiting Presentations Following Marijuana Liberalization in Colorado. Academic Emergency Medicine. Volume 22, Issue 6, June 2015, Pages 694–699
[3] Rocky Mountain High Intensity Drug Trafficking Area. The Legalization of Marijuana in Colorado: The Impact. Volume 2 / August 2014. http://www.rmhidta.org/html/August%202014%20Legalization%20of%20MJ%20in%20Colorado%20the%20Impact.pdf

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