COVID-19, Dying Patients, and Compassion Fatigue: How Can Case Managers Cope?
EXECUTIVE SUMMARY
The delta variant wave of COVID-19 has led to signs of compassion fatigue among healthcare workers.
- Patients appear angrier, and the anti-vaccine misinformation is contributing to provider frustration and stress.
- Anti-vaxxer protestors and media messages that disparage the vaccine push the message that people should do what they think is best for themselves and not worry about public and community health.
- There also are fewer volunteers and support for hospital staff and family caregivers of sick patients and hospice patients.
The anecdotal consensus among healthcare workers — at least among those who post information on social media or talk to journalists — is that they are frustrated, experiencing compassion fatigue, and view COVID-19 patients differently than they did a year ago.
“I think it’s becoming more difficult,” says Jenny Quigley-Stickney, MSN, BSN, RN, CCM, ACM-RN, case manager at Cape Cod Hospital in Hyannis, MA. “It was easier in the beginning of the pandemic, but as we moved on, there’s a lot of anger in the community, and it’s really tough. I just feel like how we could support each other in the past is not there anymore.”
The chief problem is public divisiveness, fueled by misinformation. Healthcare workers and the communities in which they work often are not pulling together as they did in the first year of the pandemic.
“I feel the divisiveness, pitting people against each other at a time when they’re supposed to be coming together,” says Joan M. Griffin, PhD, professor of health services research at the Mayo Clinic. “There is compassion fatigue. Case managers are not on the frontline, but coaching caregivers and helping them manage are difficult challenges.”
Compassion fatigue is especially challenging for healthcare workers when work demands are high, says Nada Fadul, MD, assistant dean for diversity, equity, and inclusion education programs and associate professor of infectious diseases at the University of Nebraska Medical Center. “I was just at a meeting and a few people talked about this. It’s becoming extremely tough for them, and nurses are quitting across the country because of compassion fatigue.”
A big contributor to their stress and compassion fatigue is the misinformation about vaccines. (See story on patients’ anger in this issue.)
“All those patients who are still saying COVID is not real,” Fadul says. “The damage has been done by media and anti-vaxxers, and all of that is unbelievable. I don’t know how people can go to bed knowing false advertising is leading to deaths every single day.”
Hospital work is becoming more emotional for case managers. They are seeing many patients die from a preventable disease. The patients and families they serve are fearful.
Patients’ families and caregivers also are stressed, faced with grieving during a time of disorganization, when bedside good-byes and death rituals might be difficult because of infection prevention protocols.1
One possible solution is to encourage and embrace palliative care as part of case management. The palliative care approach helps people see the holistic picture that includes the patient, the family, their beliefs, and their spiritual and psychological well-being.
“Case managers can help families identify what is the best way to transition patients to another setting that would provide them with care, comfort, and resources they need,” Fadul explains. “That’s where palliative care training can help case managers understand how the disease affects the patient and family.”
As the pandemic progresses, case managers and healthcare providers need to acquire new skills in care decision-making and effective symptom control when patients are not receiving life-saving measures.2
“Palliative care opens the door to have conversations case managers might not have had with patients and caregivers before COVID-19,” Griffin says.
For instance, case managers could ask caregivers questions about their expectations:
- What do you want the end of life to look like?
- What do you want your care to look like?
- How can we help you make those things happen?
- What are your values?
“This is an opportunity for case managers to talk to caregivers about their own needs,” Griffin explains. “A lot of these conversations are difficult to initiate, and as part of a protocol, it’s helpful. Maybe it will change the way case managers are able to approach these difficult conversations because they have practice doing it now.”
“Most healthcare providers are going through emotional trauma right now,” Fadul says.
The first wave of the pandemic was the learning phase. Healthcare providers did not know how best to care for COVID-19 patients because there were no guidelines or studies. But healthcare workers pulled together and were supported by their communities.
A year and a half later, delta variant outbreaks are causing overflowing emergency departments (EDs) and ICUs. But this time, providers know how best to treat patients. They know the course of the disease. But a system problem is stressing healthcare workers and organizations, says Hariharan Regunath, MD, FACP, FIDSA, assistant professor of clinical medicine and medical director of the progressive care unit at University of Missouri Health Care.
“We now have some answers, and the disease burden has improved. But the system issues that are not being handled — and the politicization related to that — is stressing out healthcare workers,” Regunath says. “Most healthcare systems have vaccinated a majority of their employees, but a small minority have issues and make the personal choice of not getting vaccinated.”
There is political and societal tension between the public health message that everyone should be vaccinated, wear masks, and do what they can to prevent the spread of the deadly virus and the personal inclination of people to focus on their own health priorities.
“We are focused on the selfish picture of ourselves,” Regunath explains. “Without saying what it means to the public, focusing on self-protection and what is right and your freedom alone is what is misleading people. That is major misinformation.”
Before the COVID-19 vaccines received emergency use authorization (EUA), straightforward guidelines existed: Mask up, limit people in a room and keep distances, wash hands, and sanitize. When the vaccines were rolled out, restrictions, confusion, challenges, and mixed messages arose.
“Before the vaccines came out, there were clear guidelines,” Griffin says. “Now, there are so many more wrinkles.”
For instance, health systems struggled with whether to mandate staff vaccinations because of the competing pressure from some state governments that prohibited vaccine and mask mandates, and the workforce pressure of needing enough nurses to staff the now-full beds. A minority of nurses resisted vaccination, but all hands were needed on deck.
In September, President Biden announced that vaccinations would be required for all medical facilities relying on federal funding or with 100 or more employees. Those who refuse vaccines will need to undergo weekly COVID-19 testing.3 This cleared up some ambiguity, but not all.
The federal vaccine mandate will help, Griffin notes. “If people are able to adhere to that mandate and follow it, this will be incredibly helpful to healthcare workers and caregivers to know they are not constantly being put at risk,” she explains. “It will ease the burden for some people.”
This might not be enough to prevent burnout and compassion fatigue because the enduring trauma of the pandemic and the overcrowded hospitals are not what providers imagined would happen post-vaccine.
“At this point, we thought if we got the vaccines and did what we’re supposed to do, then we’ll move out of this crisis,” Quigley-Stickney says. “Now, I just got my booster shot the other day, but the truth is I haven’t had a vacation in forever.” There also is the frightening specter of the mu variant or other COVID-19 variants current vaccines might not be able to defeat, she adds.
Case managers, nurses, and hospice staff have so much more on their plates now than they did even a year ago, Griffin notes.
“We hadn’t completely come back to normal, and then [it happens] again,” she says. “When you add on the seriousness and risks attached to transmission of the disease, it seems overwhelming to people.”
When case managers help patients transition home or to hospice, they must be aware of more limited resources and support than they did pre-pandemic. Hospitals are doing without volunteers, and family caregivers might be on their own taking care of patients’ health and physical needs.
“Things like having volunteers or friends who can come by and relieve caregivers and hospice staff of some of the work they do — those people are not back yet,” Griffin says. “They’re not back into hospitals to offset the demands of healthcare workers.”
REFERENCES
- Holland DE, Vanderboom CE, Dose AM, et al. Death and grieving for family caregivers of loved ones with life-limiting illnesses in the era of COVID-19: Considerations for case managers. Prof Case Manag 2021;26:53-61.
- Fadul N, Elsayem AF, Bruera E. Integration of palliative care into COVID-19 pandemic planning. BMJ Support Palliat Care 2021;11:40-44.
- The White House. Path out of the pandemic: President Biden’s COVID-19 action plan. Sept. 9, 2021.
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