Awareness, Education Keys to Trauma-Informed Hospice Care

Having a greater understanding around the impacts of trauma and abuse can help hospices improve end-of-life experiences for patients and working conditions for staff.

Training and education are keys to caring for patients and employees with unique needs impacted by trauma and abuse.

This is the final installment of a two-part series that digs into the ways hospice providers are addressing challenges related to abuse and traumatic experiences among patients and their workforce.

Awareness, education and empathy are three important elements, according to Dr. Balu Natarajan, chief medical officer at AccentCare.

“The first, most important thing is just creating an atmosphere of empathy and psychological safety. That’s a fundamental place to begin,” Natarajan told Hospice News. “The second is knowing how to ask the right questions upon admission. The third is moving away from a very medicalized approach and focusing on what conversations help us get informed on trauma in the past and present.”

Understanding the impacts

Types of abuse include physical, sexual and emotional, in addition to financial exploitation, neglect and forced isolation.

Seniors who have experienced abuse are at a 300% higher risk of death compared to others, according to a report from the National Council on Aging. Victims of financial abuse lose up to $36.5 billion annually nationwide, the report found.

Abuse and trauma experiences impact those delivering and receiving hospice care in many ways, some evident and some less apparent, according to Carole Fisher, president, National Partnership for Healthcare and Hospice Innovation (NPHI).

It can be difficult to understand and recognize when someone is affected by abuse or trauma. Many of the symptoms occur internally, and people can be apprehensive about coming forward, Fisher said.

“What we’re seeing is a quiet suffering when it comes to elder abuse and neglect and the people who serve them,” Fisher told Hospice News. “There are several forms of abuse that we could do a better job of raising awareness around. There’s a lot of ignoring physical, emotional and social needs – this is not uncommon.”

The emotional and mental tolls can include feelings of shame, regret, guilt, remorse, fear, anxiety and depression, Fisher said. Lasting physical and social impacts can also take root as a result of these experiences, she added.

The impacts of trauma and abuse are important to include in staff training and education, as well as patient care delivery approaches and employee policies, Fisher stated.

“It’s continuing to move forward on championing awareness and evolving into normalizing these conversations — not keeping them in a coffin,” Fisher said. “It’s about education and support in recognizing the role that trauma plays and adopting practices and policies in the world of hospice and palliative care. We have a duty to look out for this in anyone, a social worker, physician, nurse or patient. It’s teaching skills in empathy, avoiding victim shaming and helping someone feel safe, secure and comfortable in speaking out. We need to give them a voice and we have a responsibility to remove the stigmas and elevate these conversations.”

What we’re seeing is a quiet suffering when it comes to elder abuse and neglect and the people who serve them. It’s continuing to move forward on championing awareness and evolving into normalizing these conversations — not keeping them in a coffin.

– Carole Fisher, president, National Partnership for Healthcare and Hospice Innovation

Building blocks of trauma-informed hospice care

Trauma-informed care involves having a complete understanding of a person’s overall life experiences and orienting health services toward healing, according to Lara McKinnis, professional development specialist at Teleios Collaborative Network. McKinnis also has a private therapy practice and previously served as the director of patient and family support and grief services for the North Carolina-based hospice provider Four Seasons.

Misunderstandings around trauma-informed care are common among health care organizations, McKinnis stated. Organizations often lack insight around the varied types of abuse and traumatic experiences and associated mental health impacts and conditions, as well as therapeutic treatments available, she said.

“The first step is for hospice organizations to become more trauma-informed themselves,” McKinnis said. “You could be missing the mark in providing safety in your health care organization. It’s seeing and understanding what trauma is and creating this paradigm shift. In order to provide trauma-informed care, we need to first give it to ourselves. It’s looking at how much understanding you have of the ripple impacts that are just massive when it comes to trauma.”

Trauma-informed care delivery focuses on six components, according to McKinnis. These include:

• Safety
• Trust and transparency
• Peer support
• Collaboration
• Empowerment and choice
• Cultural competence and humility

Trauma and abuse survivors are coping with complex challenges and have unique needs as they approach the end of life, according to McKinnis. Those six components can help hospices develop a strategic plan to improve trauma-informed care delivery, she said.

“Domestic violence and trauma survivors can have this incredible strength, bravery and power when they have support,” McKinnis said. “But there can be many unexpected experiences that come up at the end of life that can trigger inner issues or untreated symptoms. Staff can go into these patients’ homes and care facilities and get into situations where their nervous systems of trauma are alarmed. It’s having that ability to help them and patients find safety in that situation and understand trauma response.”

Hospices need to apply a wide lens when widening the scope of assessments to include in trauma care education and awareness, according to Angie Snyder, executive director of Florida-based Opus Peace. Snyder previously served as a hospice nurse for 23 years.

Established roughly a decade ago by five U.S. Department of Veterans Affairs nurses, Opus Peace has programs for veterans who have experienced trauma resulting in “soul injury,” learning that these experiences can apply to the broader patient population as well, Snyder stated.

“A soul injury is a wound that separates the person from being their real self, caused by unmourned loss, unforgiven guilt and a loss of control,” Snyder said. “But it’s not just the dying veterans having these difficult traumatic things surface. It’s looking at a whole person and digging into these symptoms, which doesn’t mean you only look at it through a trauma lens. It’s teaching and educating staff to create safe spaces for the good, the bad, the beautiful and the ugly parts of our human stories to come out. It’s helping people heal from these experiences sooner in life so they can live healed and die healed. Hospices have a role to play in reducing symptoms from domestic violence through education to staff, patients, families and communities.”

It’s teaching and educating staff to create safe spaces for the good, the bad, the beautiful and the ugly parts of our human stories to come out. It’s helping people heal from these experiences sooner in life so they can live healed and die healed.

— Angie Snyder, executive director, Opus Peace

An important component of trauma-informed training includes not just recognizing the signs and symptoms of trauma, but also teaching staff to carefully broach conversations when a concern arises. They should also understand that pushing someone to speak up when they are not ready can cause damage, according to Snyder.

Having resources and support available is another key step to providing trauma-informed hospice care, according to Natarajan. Connecting staff, patients and families with behavioral health and various types of therapies in pet, music, art therapy or meditation and yoga can go a long way in helping them navigate difficult impacts of abuse and trauma, he said.

“It’s having a way of tailor-made treatments and therapies that address a number of trauma situations and impacts,” Natarajan said. “We can address these by making sure we have these elements built into the standard of our care and go deeper into care plans and the roles of interdisciplinary team members. We want to reduce the harm and understand a person’s individual triggers by engaging with their families and trustworthy people in their lives as well. We can then find a safe way to proceed to uncover and unpack those experiences and establish a place of trust for patients and staff.”