Reflections on a Palliative Care Response to Disaster

By Aldebra Schroll, MD, Enloe Medical Center

Editor’s Note: We asked Dr. Schroll to share her reflections of how palliative care teams are often key in responding to community crises. Her story is about the impacts of a devastating fire in northern California, but palliative care teams are on the front lines of many types of natural and human-initiated disasters – including pandemics, weather catastrophes, and indeed military invasions. Her call for systemic responses is all the more compelling in light of recent events.

Heading out the morning of November 8, 2018, I stopped to view the unusual cloud formation billowing up in the eastern sky. I would soon learn it was the result of a wildfire racing through our neighboring community of Paradise, CA. It would become the deadliest wildfire in state history.

Arriving at the hospital that morning, I found the command center open, fielding information and preparing to take in patients transferred from Feather River, the hospital in Paradise that sat on the canyon edge facing the fire’s arrival. Over the next several weeks, our palliative team would bear witness to the horror stories shared by patients and families. We were not untouched by the tragedy: Our teammate lost her home. My parents required evacuation from their assisted living site on the edge of the foothills. My sister and her husband moved in with me, while we waited for word of their home, which was spared.

Our palliative consult team saw the survivors who faced critical health crises after the fire. People fled in such a hurry that medications and lifesaving equipment were left behind. The medical community on the ridge fell apart with many providers also fleeing for their lives. Services were disrupted. We had patients with complications of brain hemorrhage and embolic strokes when they did not get routine warfarin clinic checks. We also had patients who did not have the needed pulmonary equipment they depended on and arrived in acute respiratory failure. Cancer care was interrupted. Others suffered acute injuries and stress-related events; many never leaving the hospital. To my knowledge, we never got a full accounting of those who died afterward due to complications related to the fire.

Our days were impacted by a heavy layer of smoke that hung over town, a never-ending night. Makeshift camps with RVs and tents were set up at the fair grounds and a Walmart parking lot. Our team’s nurse practitioner volunteered at the camps assisting patients who needed medication refills and medical evaluations. The needs were endless. Charities arrived to assist preparing warm meals and providing clothing as the winter weather arrived. We were living in a disaster zone.

Our work intensified. Palliative care is challenging in the best of circumstances. I often describe it as walking into the worst day of someone’s life. This was never more true than after the Camp Fire. The patients and their families were traumatized, we were assisting them to make difficult decisions under the worst circumstances.

For many of our patients, the disaster is still ongoing, more than three years later. The patients who were evacuated and/or lost homes often experienced a worsening in their medical issues. This was particularly true for those with dementia, which rapidly progressed in patients who were relocated multiple times. We are also seeing clinical decline for those with heart disease and pulmonary issues; especially when our summers bring more smoky days. Alcohol and substance abuse are major challenges. The scent of smoke and blustery winds trigger patients who are dealing with PTSD, anxiety, and depression. Many of the survivors remain in unstable living environments: in RVs and trailers, still awaiting financial settlements.

The disaster has imparted important lessons. This work of caring for others and bearing witness comes with the risk of vicarious trauma: the impact of repeated exposures to those traumatized by a variety of circumstances including natural disasters. The recurrent stories of human suffering can take a toll, with the risk of burnout. This recognition speaks to the critical need to address the well-being of staff.

Repeated traumas leave little time to heal, which has been especially problematic. The Camp Fire was preceded by the Oroville dam crisis in 2017 requiring a mass evacuation, and the COVID-19 pandemic arrived not long after. Local institutions and their staff have been under duress as a result; also increasing the risk for burnout. Discussions around how to address the issue of burnout preceded these disasters but are of critical concern at this time. We face an urgent need to respond to the trauma and despair among healthcare workers.

Historically, much of the discussion around burnout placed the onus for maintaining wellness on the individual, advising resiliency training and mindfulness among other approaches. However, the issue of burnout is a systemic issue. There is a growing body of research and recognized institutional policies to support caregivers.  

Research has uncovered important mitigating factors to prevent burnout, including feeling valued by the organization and the sense of sharing a mission. Leadership must respond in concrete ways to demonstrate their appreciation for their healthcare workers; asking “How can we help?” and “What do you need?” Then, there must be follow through to mitigate stressors.

Recommendations for moving forward include making burnout assessment and prevention organizational priorities with regular surveys to gauge needs. It is imperative to create a culture of psychological safety; mental health support and suicide prevention should be offered, assuring staff that help is available and removing the stigma of asking for help. Additional considerations emphasize providing time for meaningful clinician‒patient engagement, workload assessment, enhanced efficiency, flexible scheduling within a supportive, compassionate organizational culture.

Now more than three years from that morning, I look out on clear skies. Recovery and rebuilding are under way, although we will never be the same. The Camp Fire left scars on the land and the local communities. As I look back, I am grateful for my teammates and our palliative training, preparing us to meet the needs of those in crisis. We had all taken classes through the CSU Shiley Haynes Institute for Palliative Care. When disaster struck, I relied on my small but mighty team to help patients, families and our community face a disaster.

References:

https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(21)00370-9/fulltext

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7930845/