High consult volumes and limited resources can be an ongoing strain on the overall health and morale of palliative care teams. During the COVID epidemic, the increase in patient volumes means the team must rapidly adjust, placing additional strain on the team and individual anxiety levels are high and prompt many questions: How do I meet the needs of patients? How do I protect myself? Am I putting my family at risk?

Here are proactive steps palliative care teams can take to promote wellness during COVID-19.

Recognize that this is Different: Palliative Care Teams are Tired, Stressed and Scared

Issues Pre-COVID-19 During COVID-19
Moral Distress Are we doing enough to honor patient wishes and values? We can’t get to patients quickly enough and justice may begin superseding autonomy.
Hierarchy of Needs Team needs of psychological and physical safety intact Lethality of virus, fear of exposure, and shortages of PPE undermine this most important need.
Debriefing A formal process of debriefing with team on tough cases Teams are overwhelmed with difficult cases. Teams can adapt by using end-of-day touch-bases.
Team Strengths Expert communication and symptom management Doubling down that these are our patients this is our skill set, and this is our journey.
Scope of Practice Boundary-setting and clear scope needed to preserve our resources and protect our team Working in new settings to us (e.g., ED, COVID units, telehealth); boundaries are still important but they may be challenged and there is a need for flexibility.
Cognitive Framing We have established service standards for access and quality (timely, high-quality consults) We won’t be able to get to everyone, and we are used to doing better. We need to reframe the focus from what we can't or didn’t do, to what we did accomplish.

Assess the Team

Recognize that each team member reacts differently to stressful situations. Some members become more focused and direct, some more quiet, and others have a hard time making decisions. Be sensitive to how team members may be experiencing the crisis. COVID-19 presents a different fear/stress level based on individual backgrounds, underlying health conditions, and support at home. Examples of team member profiles include:

  • 65-year-old physician divorced, living alone with history of tobacco use, depression, and CHF
  • 29-year-old married social worker and marathon runner with a two-year-old at home

Revisit and reinforce the palliative program mission and values. Delineate the team mission and priorities to avoid leading individual team members to question their purpose or role.

Encourage and reinforce interdisciplinary professional respect. Acknowledge our different fears, strengths, and roles, and ensure everyone has a safe space and voice in what is happening (i.e., all team members, whether at home or on-site still have equal importance and voice).

Acknowledge and Be Prepared to Support Unique Stressors Associated with COVID-19

Some examples of these stressors include:

  • Fear and worry about your own health and the health of your loved ones
  • Changes in sleep or eating patterns
  • Difficulty sleeping or concentrating
  • Worsening of chronic health problems
  • Increased use of alcohol, tobacco, or other drugs (i.e., chemical coping)

Support Each Other in Healthy Coping Strategies

Take breaks from the focus of COVID. This includes talking about, watching, reading, or listening to news stories, including social media. Hearing about the pandemic repeatedly can be upsetting and exhausting.

Nurture physical needs. Take time for mindfulness, deep breathing exercises, meditation, prayer, stretching or walking. Encourage healthy eating (a mix of protein, grains, and vegetables). Integrate restorative measures such as rest/sleep and exercise. Find healthy outlets for distraction (hobbies, reading, games, dancing, music) rather than chemical coping.

Encourage team members to take time away from the ‘crisis focus’ to recover; focus on personal time and family time.

The team’s emotional health is a collective responsibility, which includes:

  • Mutual support among team members
  • Soliciting assistance for support from outside (e.g., Employee Assistance Programs (EAP), private counselors, spiritual providers)
  • Team members taking responsibility for their own emotional wellness

Refine Your Team’s Boundaries and Roles: Know What You Own

Palliative care should be at the table for health system/organization decision-making and crisis management in reaction to COVID-19.

Be clear about the palliative care team’s responsibilities and role. Palliative care’s role is to relieve suffering through expert communication and symptom management in serious illness and crisis. The palliative care team will play a large role in communication about care needs and relief of suffering for patients and families, and in providing support to overwhelmed colleagues.

Re-establish team expectations (e.g., changing from high-touch, face-to-face patient care to telehealth, doing the best care possible in a crisis, managing census in a surge of patients).

Share Joys and Grief

Acknowledge individual team members’ contributions, and communicate team accomplishments. Offer shout-outs that reinforce team values or create an opportunity for laughter.

Continue or develop team rituals devoted to the emotional aspect of the work, such as remembrances through weekly or monthly time. As a team, acknowledge feelings of individual loss and suffering related to specific cases, and conduct team debriefs on difficult cases.

Encourage Resilience Strategies

These strategies are adapted from the Duke Healthcare Quality and Safety Center:

  • Practice gratitude: focus on three good things, within two hours of bedtime (if possible, write them down). A commitment to do this for two weeks helps your brain re-frame to scan the environment for the positives. Data shows that people who did this exercise had less depression, even six months after their two-week commitment.
  • Try resilience writing: write non-stop about an emotionally difficult subject for 30 minutes every day for three days. This helps move emotional events from the amygdala to the hippocampus (emotional to cognitive) and promotes healing.

Improve Your Work from Home Experience

The following tips for working from home are adapted from Yale New Haven Health:

  • Maintain regular hours. Set a schedule for when you’ll be working from home, and stick to it every day.
  • Create a morning routine that signifies the start of your work day. This may be eating breakfast, taking a shower, getting dressed, then making a cup of coffee and sitting at your work space.
  • Set ground rules with people in your house. Communicate about when you’re working and what you’ll need.
  • Schedule breaks. Remember to get away from your computer to stretch and get in some physical activity.
  • Create an office space. Dedicate a desk/table space to working from home. Ensure you have your computer and any other supplies you need.
  • Socialize with colleagues. Make time to talk informally like you would in an office.
  • Mark the end of your work day with a routine that signifies you are switching from work time to home time.

Tips for Managers

The following tips for managers are adapted from Yale New Haven Health:

  • Foster a high-trust culture. Managers have hired employees to do their jobs, and need to allow staff to feel empowered to do their work.
  • Know the balance between check-ins vs. micromanagement. Listing every piece of work is not productive for anyone.
  • Set parameters for virtual meetings, and stick to them. Be clear about start time and stop time. Be respectful.
  • Respect and accept that there is a learning curve, and that productivity will go down before it goes up. Too much is happening at once, and people process in different ways. Once everyone has established a “groove,” productivity will go up.
  • Practice empathy and show your human side. It’s ok to admit that everyone is struggling with the ‘new normal’, including you as the manager. Share your struggles.

Additional Resources

Strategies for Maximizing the Health/Wellness of Palliative Care Teams: Resource for orienting new team members, defining team goals and attributes, and understanding team health and function

CAPC Virtual Office Hours: Small group calls with CAPC faculty to discuss challenges and ideas for navigating the COVID-19 pandemic

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