Self-care of physicians caring for patients at the end of life: "Being connected... a key to my survival".

Physicians providing end-of-life care are subject to a variety of stresses that may lead to burnout and compassion fatigue at both individual and team levels. Through the story of an oncologist, we discuss the prodromal symptoms and signs leading to burnout and compassion fatigue and present the evidence for prevention. We define and discuss factors that contribute to burnout and compassion fatigue and consider factors that may mitigate burnout. We explore the practice of empathy and discuss an approach for physicians to maximize wellness through self-awareness in the setting of caring for patients with end-stage illness. Finally, we discuss some practical applications of self-care in the workplace.

The wounding path to becoming healers: medical students' apprenticeship experiences.

BACKGROUND: This article responds to repeated calls in the literature to teach medical students how to treat the whole patient, not just the disease. It focuses on the educational experiences of medical students in a Canadian university in an effort to clarify the determinants of "caring" in medical education. METHOD: Nineteen (19) second-year medical students volunteered to keep weekly journal entries during the first five months of their medical apprenticeship. In journal entry analyses, the authors identified themes through a consensus-building coding process detailed in the work of Maykut and Morehouse (1994) and Huckin (2004). For this article, the authors focus on those themes most closely related to the students' caring experiences during their apprenticeship. RESULTS: The data highlight components of the medical system which made it difficult for students to engage in caring practices during their apprenticeship: the competing discourses of empathy and efficiency, the objectification of patients, the power of the medical hierarchy, and the institutionalized practice of wounding. CONCLUSION: The authors argue that returning medical care and students' experience to a balance of attention to curing and caring is a complex undertaking requiring a re-conceptualization of the process and goals of medical care.

Healing connections: on moving from suffering to a sense of well-being.

Life-threatening illness is an assault on the whole person--physical, psychological, social, and spiritual. It frequently presents caregiver and sufferer with a paradox--suffering does not correlate with physical well-being alone. Drawing on a purposive sample of 21 participants, a phenomenological study was carried out to explore the relevance of the existential and spiritual domains to suffering, healing, and quality of life (QOL). The phenomenological method was used to achieve an in-depth description of both existential suffering, and conversely, the experience of integrity and wholeness, in persons with life-threatening illness; identify "inner life" and existential contributors to suffering and subjective well-being in advanced illness; and develop a narrative account of these QOL extremes. The importance of meaning-based adaptation to advanced illness was supported, as were Frankl's sources of meaning and Yalom's sources of existential anguish. Divergent themes characteristic of the two QOL extremes were identified. Four types of "healing connections" involving a sense of bonding to Self, others, the phenomenal world, and ultimate meaning, respectively, were identified. They situated the participant in a context that was greater and more enduring than the self, thus leading to enhanced meaning and QOL. The assumptions underlying the construct "health-related QOL" are questioned.

The caregiver's perspective on existential and spiritual distress in palliative care.

There is a paucity of research relating to how palliative caregivers conceptualize, identify, and provide for spiritual and existential domains of care. Focus groups comprising experienced palliative care providers participated in three semistructured 2-2.5 hour interviews, which were transcribed and subjected to thematic analysis. Eight themes were revealed: conceptualization of spirituality; creating openings; issues of transference and countertransference; cumulative grief; healing connections; the wounded healer; sustaining a healing environment for the caregiver; and challenges and strengths for the spiritual and existential domains of palliative care. While the spiritual and existential domains were variously conceived by experienced care providers, their significance for both patient and caregiver was affirmed. Transference and countertransference issues and the "wounded healer" concept were considered fundamental to effective care. Strategies for promoting therapeutic depth discussion were suggested and the importance of self-awareness and staff support emphasized.

Psychological Impact of Urologic Cancer.

All involved in the therapeutic alliance feel stress: the patient, the family, and the care giver. Uncertainty breeds anxiety. Distress is minimized when all concerned have a shared, clear understanding of therapeutic goals and when emphasis is focused on what can be done. Openness concerning diagnosis and prognosis demands sustained and supportive follow-up. A shifting balance between denial and integration of reality usually exists. Irrespective of outcome, the patient and family cope with loss and uncertainty. In the presence of progressive illness, repeated losses compound the adjustment problem. Anticipated disfigurement due to radical surgery, alterations in body image particularly where sexual function is concerned, the necessity of urinary or fecal diversion, and side effects of therapy all require careful psychological preparation. Staff burnout may be minimized by attention to staff selection, training, supervision, support and communication. The bereaved constitute a high-risk population. Even a simple follow-up program may help them to adjust to their loss.