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Okay, so welcome everyone. My name is Chelsea Perez. I'm an education associate here at CAPC.

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Very pleased to welcome you to today's webinar, Trauma-informed Care, why it's important and how to implement it into practice.

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This helps us continue to improve our virtual offerings. Onto today's session, we're very lucky to be joined by our presenters, Dr.

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Shrika Newman, Associate Medical Director for Center World Primary Care Anywhere, Georgia. And Dr.

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Karen Block endowed professor of social work at Boston College. So with that, I'll go ahead and hand it over to our presenters today.

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Good afternoon, everyone. Chelsea, you'll be advancing the slides. Thank you.

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I'll read the disclosure statement, neither Dr. Newman or I have any other. Disclosures.

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We have no conflicts of interest or financial disclosure to declare related to this presentation.

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I'd like to begin our discussion of This patient is a fictitious patient. We'll start with this patient vignette to set the tone.

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Mr. Willie Jenkins is an 87 year old widowed black African.

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American cisgender male. Who also is of Baptist religion tradition. And he has 22 years military career experience in the US Air Force, Vietnam.

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War veteran as well as the cultural context that Mr. Jenkin, so we'd like to frame for you to consider, Mr. Jenkins, this is extremely important.

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One, because.

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Mr.

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In.

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Is an older adult who most of us would know that during his health care as an adult, there were times in which he would have experienced structural systemic racism because US health care systems were legally and structurally racially segregated until 1965 and we know that many healthcare settings didn't comply until late into

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19 seventys and so Mr. Jenkins would have experienced the structural racism in his lifetime in terms of accessing health care.

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Also, they're the religious context of being Baptist and his spirituality and how he might, how this might inform his decision-making as well as his career military experience because as we know

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Military has his own culture and oftentimes very little is spoken about this culture. Mr. Jenkins is alert, competent, and able to make decisions.

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So this is a critical piece as well for consideration. And in terms of his health care decision makers, he has his next of kin who's a 75 year old brother visiting from Georgia.

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Who like Mr. Jenkins will have experienced historical structural systemic racism. And his sister-in-law who engages in Mr. Jenkins care as well.

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Next slide, Chelsea. Thank you. The patient's medical history. Is this such poorly controlled diabetes, tobacco use, stage 3, chronic kidney disease, he has a heart failure infraction of 30%.

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D with multiple hospitalizations. One of the concerns is the recent decline over the past few months, Mr. Jenkins is experiencing increased frailty, weight loss, increasingly as reported by his family members and himself.

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He requires assistance with his instrumental activities of daily living, transportation, other structural supports, as well as his ADL such as bathing dressing feeding and and his sister-in-law has moved in recently and he also has home health aid.

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So these are supports that. Has available to him. 3 months ago, at a PCP visit, he politely resisted discussion of overall goals of care or completion of a pulse or most form.

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This is important because again with Mr. Jenkins decline in health when possibly we want to try to introduce these conversations when he has the decision-making capacity so that we can fully engage him in the discussion.

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Mr. Jenkins was admitted then to the unit yesterday with increased labor breathing thought to be related to his COPD exacerbating and volume overload.

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So again, critically important that we think about how we can introduce these conversations and when with a patient of Mr. Jenkins age or any age but that has these concerns about health decline and while he has available supports.

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Next slide, Chelsea.

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So on morning rounds, Mr. Jenkins is feeling slightly less labor intense breathing and you're worried that it's condition may worsen due to his high risk of rapid decline.

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Remarkably, Mr. Jenkins has not yet developed hospital acquired delirium. This is really important as well because oftentimes we see patients that begin to experience deliver delirium, which makes it more challenging us for us to fully engage him in goals of care conversations, especially the ones that we need to have with the patient like Mr. Jenkins with rapidly declining health.

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And so you feel you as a clinician feels some urgency to discuss the goals of care with Mr. Jenkins, with his family members, Dana's his sister-in-law and his 75 year old brother Charles who has come up from Georgia with his granddaughter Maya to engage in care.

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This is not an uncommon patient that we see, especially patients of African-american descent who tend to utilize informal supports throughout their care.

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Next slide.

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So as we proceed, the question for you in the audience is how would you proceed with this patient? Just using this brief synopsis.

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Most likely you would want to ask about the symptoms and comfort, which is really important because we know that our patients can't fully engage in conversations if their symptoms aren't managed and if they're not comfortable.

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We need to elicit values and care preferences for communication. How would the patient want to engage in this conversation if he, she, they were to engage in conversations.

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It's important to know who would they want to have in the conversation or not in the conversation and what are the things that would be really important to them and even considering or contemplating this type of conversation about goals of care and serious illness.

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Explore the patient's understanding of what has been shared about any care plan that the patient has in place.

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It's really important to ask the patient about their understanding of the plan because the medical team may think that they have provided information in one way that may be interpreted differently by the patient and or the family.

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So we would want to Understand what the patient is interpreting as a care plan or not. And then explore the patient's lived experiences with access and care through a trauma-informed approach.

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And again, I emphasize lived experiences because patients have a range of different lived experiences that absolutely influence their decision-making and the way in which they engage in goals of care.

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Next slide.

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So we can think about trauma-informed care in connection with adverse childhood experiences. So we're talking about Mr. Jenkins, an 87 year old male who clearly is an older adult, but we're going to emphasize how important it is for us as clinicians to understand a person's lived experiences inclusive of what may be potential adverse childhood experiences.

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We cannot incorporate these into The care plan if we haven't had a discussion with the patient and or family or if we don't have good assessment tools to understand what may be influencing ones behavior and these behaviors may be mislabeled or misunderstood in the absence of assessments and conversations.

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So I'll frame the discussion of trauma-informed approach to this. So thinking about how to engage a patient around greater understanding about child adverse childhood experiences or any other experiences considering a patient like Mr. Jenkins who has military career history, veteran experience, religious influences.

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History of experiences with historical structural racism. So I want to frame this discussion as Dr. Newman and I will have with you this today.

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About trauma informed approaches and how it acknowledges that health care organizations and care teams need to have a complete picture or as complete as possible of the patients.

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Lived experiences, their life situations both past and present in order to effectively provide holistic care. That is culturally sensitive and culturally responsive.

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Excellent, Chelsea.

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Therefore, a trauma informed approach to care is important and trauma-informed care is essential.

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Trauma affects a significant portion of our patients, yet it is often overlooked in clinical training.

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Of all disciplines. Understanding the impact of trauma is crucial for providing person-centered care to seriously ill patients.

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It enables clinicians to gain insight about factors that might otherwise be mislabeled or misinterpreted.

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Next slide.

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Integrating trauma-informed practices can potentially improve patient engagement. Treatment adherence and goals of care outcomes.

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It can also help the clinician to understand what happened instead of what is wrong. And oftentimes we revert to the what is wrong without consideration of what happened prior to our engagement with the patient or prior to the patient's diagnosis with the serious illness.

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Next slide.

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So in thinking about a patient and we'll use Mr. Willie Jenkins as an example and to have a trauma informed lens.

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We would want to start with thinking about what is trauma, making sure that we have some understanding of the trauma inform framework.

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So trauma can be the experiences of an event or action or interaction that harms or threatens one's safety or control of circumstances or choice.

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And if you think about Mr. Jenkins and his lived experiences as out Let's find in that 1st slide.

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There might be a host of things that we would want to consider with a patient like Mr. Jenkins.

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We prepare for goals of care conversations and also as his health is clearly declining rapidly. Also thinking about the fact that, I'm sorry, can you go back Chelsea for a moment?

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Also thinking about the fact that these experiences result in lasting adverse effects. Limiting one's ability to function and achieve mental, physical, social, emotional, and or spiritual well-being.

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And so as we think about this trauma informed framework in the understanding, one of the things that Dr.

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Newman and I are encouraging you to consider throughout this webinar are the personal event trauma framework so the individual may have had a personal experience.

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That resulted in trauma. There is secondary trauma that a person might experience by engaging with someone around a certain scenario or experience in which that person experienced trauma that might remind the individual of their own trauma which can then influence their decision-making and health care outcomes as well.

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There's the collective trauma, that trauma, which is experienced by groups of people or entire communities or entire populations of people.

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And then there is the exposure to trauma in which an individual might experience that may also inform how one is making decisions about their health care or not.

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Next slide, Chelsea.

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Furthermore, the effects of these traumatic experiences present differently across patient populations across individuals, across groups, etc.

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People are not a monolith as we know and neither are their experiences. So a patient might present to having experienced complex or complicated grief from a death or loss.

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Where is some patients might not present in this way. So we need to be mindful of the fact that these traumatic events Look differently in our patient populations, which require us to use very evidence-based tools, if you will, so that we are not re-ing our clients as we try to explore or we aim to explore traumatic events.

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A natural disaster could be a traumatic event that might impact how one makes decision about their health care and it might look very different than someone who has experienced a type of abuse or neglect that could have resulted in trauma.

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And then there's also experience like racism, which is gradually making its way into the literature. As consideration as a traumatic event but many of our patients especially those like Mr. Jenkins who have lived through and continue to experience structural and systemic racism, it's critically important that we have assessment tools that enable us to have those conversations so that we can provide the best possible care.

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For all patients. Next slide, Chelsea.

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So again, as you consider why trauma informed care matters in palliative care, again, emphasizing that patients with serious illness often have a history of trauma and it is important for us to recognize and address these issues as we aim to provide holistic care and to do so in ways in which we do not re traumatize our patients simply because we have a need to gather information.

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When our ultimate goal is to improve the overall all quality of care.

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Okay, and I would like to turn this over to Dr. Newman.

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So we talk about how to explore if your patients have trauma. So this lecture is really geared towards the provider clinician relationship and how we can evaluate a patient for trauma.

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So one what we know is aces which are adverse childhood events are traumatic events that occur in childhood and Lesics causing physical, emotional, or sexual abuse.

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It can be witnessing violence in the home. Having a family member attempt to die by suicide or growing up in a substance abuse house or mentally.

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House with mental health issues or instability like separation divorce incarceration. And so ACEs cover 10 distinct areas from abuse neglect to household dysfunction.

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And what we know is that 61% of adults have at least one ace. And 16% have 4 or more aces.

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So that's just telling you in this world and where we practice a large number of our patients present with trauma, whether we know it or not, present with some type of ace whether we know it or not.

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So ensuring we are aware of this and know how to treat it so that we're not retraumatizing patients, mislabeling them, I think for me, I know I feel like a lot of patients got labeled as non-compliant.

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When really they were probably just a traumatized patient and we didn't have trauma-informed care or trauma-informed approaches to address their needs.

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Next slide.

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So what we also have recently learned is ACEs actually increase mortality. Sick people with 6 or more ACEs died nearly 20 years earlier on average than those without an A's.

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And I think this speaks to our patient population because we care for the seriously ill patient and people persons who had 4 or more.

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ACEs compared to those who had 9 had a 4 to 12 fold increased risk of alcoholism, drug abuse, depression, and suicide attempt.

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So when we think about all our patients we care for with alcoholic cirrhosis or HCC from alcoholism.

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We need to also go in with the trauma-informed approach. We know that alcoholism is a disease, but it has an underbelly and an ideology that many of us haven't explored what happened as Karen say versus what's wrong with them.

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Why can't they just stop drinking? Well, what happened to them. To make them choose this as their coping mechanism is what we need to frame this as.

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So I encourage you if you have a patient that you feel is difficult or you just like something like why would they come for my help but not receive it or we've talked to them about this thing.

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I would explore you to say instead of, well, what's wrong with them to what what has happened and be just naturally inquisitive and you can use the ACEs, their ACEs has 10 questions if you Google the AIS questions, you will get all kinds of things.

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You can ask those 10 questions and explore it. 4 people with ACEs, 4 more ACEs have a 2 to 4 increase with the smoking poor self rated health and $50 self-intercourse partners in sexually transmitted diseases and 1.4 to 1.6 have an increased risk of obesity in inactivity.

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So this. ACEs trauma, expands across a wide range of medical conditions and therefore mortality.

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Next slide.

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So this slide just it has the ACE pyramid that is found on the CDC website and the number of categories of childhood of ACEs shows a graded relationship to the presence of diseases in your adulthood.

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So if you start at the bottom with generational embodiment or historical trauma and work your way up as these are compounded as trauma is compounded.

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At least to earlier death and toxic stress. Can lead to neurological effects on the brain and how your body responds to stress because our brains are wired.

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To to act and feel before we think. So a person that is traumatized can be easily triggered.

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We know about it in our war veterans, but have we thought about it in patients like Mr. Willie Jenkins?

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Okay, who's not just a war veteran, but he lived through the Tuskegee trials who's not just a war veteran, but now he's a widow and we don't know what family history has impacted him.

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Now that he's a widow and is feels alone. So we don't we don't know all these granular things but we don't know how stress shows up and so.

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We need to treat Mr. Willie in a way that is very trauma-informed and very loving because of his experiences and we don't know how his body has taken on this stress and what his trauma response.

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Maybe his reluctance to talk about his advanced directives and talk about what he wants is his body responding to stress.

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Could be a neurological issue, a neurological stressor. So I just want us to be more mindful as we go into these approaches.

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Next slide.

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The consequence of annoying trauma is I think especially in our fields, we have a very sensitive patient population.

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They're already vulnerable by being in our settings and they're already have something seriously ill. So I think untreated trauma can manifest as non-compliant.

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I always just say I don't know why they're help health seeking but help rejecting right but now I'm like oh those patients that I've been thinking of like why are they doing this all these years I never explored their trauma so I think Okay.

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Ignoring trauma can definitely retraumatize patients and also diminish morale and put up resistance.

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Next slide.

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So trauma really to me needs to be addressed. Trima informed care, I'm sorry, needs to be addressed across all levels from the clinical level to organization into systems.

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And while we're not covering organizational systems, we do have stuff in the toolkit that can cover it.

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There are some organizations that have taught trauma-informed care and do trauma-informed practices and organizations that really even look at not just the trauma-informed care from pay from provider to patient or system to patient but also staff members because if 16% of America or the world has 4 or more ACEs, then we got to know that some of us have them.

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And some of our colleagues and some of the people we work with. And so we are also products of a trauma in trying to provide care to traumatize people.

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So it's important that organizations look at this trauma-informed approach as a totality.

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Next slide.

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There were 6. Organizations that were early adopters of trauma-informed care and the link is at the bottom.

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It this link describes those 6 organizations efforts to do trauma-informed care within their system. They did 69 interviews with the staff.

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Members and stakeholders. This was about, 2,017. It just talked about some of the implementation barriers to change, some of the training that may be needed.

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So if you're looking into seeing what others have done in trauma informed care. This is a pretty good place to start.

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Next slide.

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Also, I recently met Dr. Clearborne who is actually, working with organizations to make them a safe place, make them a non-traumatized place for staff and caregivers.

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And she has a whole curriculum we can all get CMEs through her programs. She can work with your organization.

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So if you're looking to bring in someone that can help your organization learn to be trauma-informed, she doesn't neural linguistic training, all of that stuff.

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So I wanted to make sure that you guys know the other resources that are out there for your organizations as a large or small as for the whole organization or just the group.

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So just know that these slides will be available to you and Dr. Clearborne was wonderful and gracious enough to provide her us with her information.

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And as you can see it has the learning objectives and everything that you could take back to your organization about.

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Why you're interested in providing a trauma informed care to your team. Next slide.

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So this is, the trauma-informed toolkit. I think we loaded it up in.

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March was it Karen maybe? I don't I can't remember now. But it includes 23 resources about how to implement trauma-informed care in your organization it gets some historic historical references it has the SAMHSA information in there just a whole bunch of resources and strategies and of course Karen and I, emails are on caps.

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So you can definitely email us if you have questions. About how to get your organization more trauma formed or how you yourself as a clinician can really implement these strategies and the stuff that we're talking about today.

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I personally has began incorporating the ACEs kind of into my history and physical upfront because some what I saw and I don't know if Karen can speak to this but sometimes when we recognize the thing the person is already traumatized or re-traumatized and when we come back in to X trauma questions there's a little bit more resistance whereas if we're just incorporated in our history and physical

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where we already asking them a million questions about everything about them, about their mom and their dad and their sisters.

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It just seems like more of the questions that are embedded in there. So I tend to put it there and if we discover any ACEs, then it just becomes a part of the treatment plan for us to make sure we're approaching people with with a trauma informed approach.

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Next slide.

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Based on what we've discussed. How confident are you and we're going to I think there's a poll Chelsea might keep me honest.

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How comfortable are you implementing Toronto and trauma informed care into your practice? Is there a pole?

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Kelsey? Yes. So if you could, take the poll for us, very confident, confident.

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Somewhat confident, not very confident, not confident at all. And we want your honest opinion because this can guide us to what we next best practices, next space steps, things like that.

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And Shirley, if I may, while people are taking a few moments to complete the polls, I know it can take a moment or 2 to transition to that.

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I just would like to follow up with the comment in regards to your statement about incorporating a trauma informed lens through the assessments.

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The outcome of incorporating these questions as you've already indicated while we're already asking all these questions is.

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It can actually help to inform us about some of the behaviors that we're seeing that sometimes we don't know how to label them.

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We're not sure where they're coming from. It might be that the person is uncomfortable with being in a room alone with you and you might feel I'm the kindest nicest most compassionate clinician and you might not think that this person might be uncomfortable in the space with you.

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I've observed that when the patient wasn't comfortable but didn't want to tell the clinician I'm uncomfortable with being alone with you in the room.

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I mean, it could be something that we are misidentifying because we have an incorporated this understanding about the fact that trauma might be the reason why the person is engaging with us.

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In this particular way. So I just wanted to emphasize that as I. I appreciate your comment about incorporating it into your usual standard.

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If you will, assessment with the patient.

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Do we have the results?

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Yes, can you see those on your screen?

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Yes.

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Next slide.

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Chelsea, the poll results are still in the way. If you can you take those down?

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All right, and if anyone's still seeing them in the way, you might be able to click the little x to close it out.

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And I will just for a moment introduce the idea of the trauma-informed approach in incorporating what is often referred to in the literature as the for R's.

00:29:11.000 --> 00:29:33.000
And as we both have been emphasizing, it's important to realize the widespread prevalence of trauma in the lives of patients that we're caring for and incorporating it into your standard or usual assessment as Shirika has said would be an ideal place to incorporate such questions.

00:29:33.000 --> 00:29:47.000
One, you have to realize that it's widespread in the prevalence and then also recognizing how trauma affects all individuals involved with the program that you might be working with or your organization or your system of care.

00:29:47.000 --> 00:30:05.000
But also emphasizing that it might be a workforce issue as well. Perhaps individuals who are working in serious illness care themselves are experiencing some moral distressed that might be related to something that was traumatic in your own health care setting or elsewhere in your life as well.

00:30:05.000 --> 00:30:06.000
So in thinking about trauma-informed practice for our patients and families, we also need to be thinking about it.

00:30:06.000 --> 00:30:18.000
With among our teams and within the palliative care workforce. And then the. How do you respond?

00:30:18.000 --> 00:30:32.000
So we don't want to incorporate a set of questions that we're using or have an assessment that asks specific questions that reveal information that then we're just going to leave in a medical record someplace.

00:30:32.000 --> 00:31:02.000
We need to think about and this will vary from setting to setting depending on your sort of capacity to provide, to refer if you have a social worker on your team or if you are the social worker because oftentimes social workers are leading the assessment process and so we need to have resources available to us so that once we discover these kinds of adverse experiences or traumatic experiences that we can actually be action oriented with it, discussing it, Asherika has said

00:31:04.000 --> 00:31:17.000
as a part of our comprehensive care plan for individual for the the patient and for the family. And then we need to also resist the as someone commented in the chat box.

00:31:17.000 --> 00:31:40.000
Resists the labeling of our patients when they have experienced these. And as Sharika has said, avoid thinking about non-compliance non-adherence, but to better understand what might be getting in the way of why this person is not someone like Mr. Jenkins not ready to have a conversation about goals of care when we think it's so critically important.

00:31:40.000 --> 00:31:50.000
We need to resist the pejorative as we said earlier this sort of deficit model framework that we're often working from and use more strength based language as we say in social worker meeting the patient where they are.

00:31:50.000 --> 00:32:09.000
To understand what might be different for this patient and not just making an assumption that is educational or because of this person's race, we're going to conclude that they're not going to engage in this conversation or they're not going to complete this advanced directive.

00:32:09.000 --> 00:32:24.000
We want to resist those kinds of labels and we want to resist that framework knowledge if you will that we have oftentimes applied in serious illness care to patients that we deem resistant or hard to reach.

00:32:24.000 --> 00:32:25.000
Next.

00:32:25.000 --> 00:32:29.000
So I just, you know, Karen, I've shared this story with Karen before.

00:32:29.000 --> 00:32:43.000
And I think this was one of the, when we talk about the 4 R's, one case that stands out in my practice is a young woman who was, one case that stands out in my practice is a young woman who was terminal from a cervical cancer is a young woman who was terminal from a cervical cancer who had a terminal from a cervical cancer who had a very loving family.

00:32:43.000 --> 00:32:51.000
They were calling on the hospital regularly daily actually to get up input her sister and children and she refused to have visitors.

00:32:51.000 --> 00:33:02.000
And the story, the single narrative story at the nurse's station is that she's difficult, she's mean, she's all these things.

00:33:02.000 --> 00:33:11.000
And I remember sitting there going. Something happened to her. This is before I knew about all this trauma informed approach.

00:33:11.000 --> 00:33:14.000
I just organically said someone who has a loving family. Who's calling every day who doesn't want them here?

00:33:14.000 --> 00:33:23.000
Something happened. And so. I went in, I sat with the patient, I palliated.

00:33:23.000 --> 00:33:38.000
I just I knew the palette of skills, which I think work very well when we talk about trauma-informed approach, a lot of our palliative skiers can be skills can be seamlessly integrated.

00:33:38.000 --> 00:33:57.000
If she had. Sexual abuse history. And she said no. And then I asked her what she was afraid of and she shared that with me and I said, hey, I know that you're in your last days, but I think it's wonderful if we leave this earth with people that love us around us.

00:33:57.000 --> 00:34:03.000
And I said, and so I really want to call your family and let them come here in love on you in your last days.

00:34:03.000 --> 00:34:19.000
And she just began to weep. Because I don't think any of us had given her.

00:34:19.000 --> 00:34:25.000
And I remember going back to the nurse's station thinking, I'm going to make sure I do that going forward.

00:34:25.000 --> 00:34:30.000
And I think that's the true integration of palliative care in the trauma-informed approach.

00:34:30.000 --> 00:34:33.000
And I think that's the true integration of palliative care and I think that's the true integration of palliative care and the trauma-informed approach.

00:34:33.000 --> 00:34:35.000
Had we known her ACEs, had we known her ACE, of palliative care in the trauma informed approach.

00:34:35.000 --> 00:34:39.000
Had we known her aces, had we known what happened to her before we got to this point, then it would have been a different story.

00:34:39.000 --> 00:34:49.000
You know, I asked her sister, her sister said that she had never told her that she was had a sexual abuse history but her sister had a high suspicion that it happened based on some things.

00:34:49.000 --> 00:34:56.000
So I think if we get Okay. The ACEs are able to obtain it upfront. It makes.

00:34:56.000 --> 00:35:05.000
Dealing with the challenges or what we see challenging later on so much easier because it makes us go into a softness.

00:35:05.000 --> 00:35:09.000
It makes our approach very gentle because we can see we don't want we're not here to hurt people in our profession. We really are helpers organically.

00:35:09.000 --> 00:35:30.000
So it makes us go into the help. I also think since racism is trauma? I think this is very, you.

00:35:30.000 --> 00:35:38.000
Mean that sometimes cross culturally they do not want to say the wrong thing or do the wrong thing and I know all of us have felt that way.

00:35:38.000 --> 00:36:00.000
So I think if we use trauma-informed care as this as an approach, it can really address any cross-cultural or racial biases that may be present because racism is trauma and we can just approach it in this way and it's not as heavy for you as a provider.

00:36:00.000 --> 00:36:20.000
And Trick, if I may extend that conversation a bit. Taking the example of Mr. Willie Jenkins and I have to say that Mr. Willie Jenkins is a patient I've seen many times, meaning I have worked quite extensively with older black Americans who were born in the US who were legally denied access to health care systems.

00:36:20.000 --> 00:36:29.000
When we are working with these patients in especially those these patients who are engaged in decision-making about their health care.

00:36:29.000 --> 00:36:52.000
It is really important that we have a baseline level of knowledge and understanding about structural racism. And to the point that you were making about racism as trauma, I want to emphasize this in case, you know, another way of thinking about it is for someone like Mr. Jenkins who for whom they were legal repercussions.

00:36:52.000 --> 00:37:08.000
Healthcare repercussions for trying to access care and receiving what we now term equitable care. Having this baseline level of understanding will help us to rethink How we view these patients who need more time.

00:37:08.000 --> 00:37:21.000
These patients who are not ready to make these decisions that we feel we have such a short period of time that we need to be able to meet them where they are and give them the time to process what we're asking.

00:37:21.000 --> 00:37:35.000
Them in the context of their lived experiences because when you have experienced racism It doesn't just go away after the incident, in the same way we were speaking earlier about trauma in general.

00:37:35.000 --> 00:37:55.000
You might have a 1 personal experience that might live with you for the rest of your life. But with the collective experience, someone like Mr. Jenkins who throughout his lifetime for most of his adulthood, he has been re-injured and re-injured with structural racism, which is oftentimes the case.

00:37:55.000 --> 00:38:17.000
And if you take the time to have conversations with these patients as Sharika as you said, having lived through things like the Tuskegee experiment and even that label of Tuskegee experiment can be retraumatizing because I know in a qualitative study that I did with older black Americans what they said to me is we really need to stop calling it the Tuskegee experiment.

00:38:17.000 --> 00:38:31.000
It was the Cdc's experiment. And so as we continue to label and and mislabel, we can be re-traumatizing individuals and I think we need to really think about that as we engage patients in serious illness decision-making and conversations.

00:38:31.000 --> 00:38:37.000
And so with Mr. Jenkins, I think the approach to him is to sit down and say, hey, Mister Jenkins.

00:38:37.000 --> 00:38:41.000
You've been in and out of the hospital. Wow. Tell me what you're thinking, right?

00:38:41.000 --> 00:38:47.000
The ASTEL S in palliative care still works, right? That's, that's almost a trauma approach by itself.

00:38:47.000 --> 00:38:56.000
And then I like a lot of times as far as recognizing if I haven't done the ACEs already, then I just hate, say, hey, share, tell me something about your life.

00:38:56.000 --> 00:38:57.000
What did you do for a living? What was growing up like I kind of get people to tell me their narrative.

00:38:57.000 --> 00:39:10.000
Because people will tell you the trauma in the narrative. So that's 1 approach to do if you have it done the aces.

00:39:10.000 --> 00:39:27.000
So you could ask Mr. Jenkin to tell me the narrative. And then I would simply ask, Hey, what's so what's hard about talking about what you want for your future.

00:39:27.000 --> 00:39:42.000
To address it and then whatever they decide is fine with me then I talk about that so just in that recognizing that there may be a trauma there with Mr. Jenkins, it can inform how you talk.

00:39:42.000 --> 00:40:06.000
If you haven't done ACEs, use a narrative story. Use a lot like what dignity therapy does let you let the patient tell the narrative but as you guys know we have to be seated we have to be eye level you have to be inclusive of the family and then you'll get what you need and then you will get a response and then definitely the resist For me, it's most of the time just having that conversation with

00:40:06.000 --> 00:40:24.000
our colleagues to say, hey, let's change the narrative about Mr. Jenkins. But

00:40:24.000 --> 00:40:30.000
The narrative a lot of times in the South because I practice in the South. So most people below the B, but have what we call nicknames or preferred names.

00:40:30.000 --> 00:40:40.000
And I always ask my patients for their preferred name. And I'll share that during this time with the family, right?

00:40:40.000 --> 00:40:48.000
So maybe he's called Big Willy. I'll be like, hey, listen. He prefers Big Willy and he has a whole story.

00:40:48.000 --> 00:40:49.000
He has a whole narrative.

00:40:49.000 --> 00:40:53.000
And that reframes it even for our colleagues and that helps with the resistance of this single story narrative that we sometimes perpetuate in healthcare.

00:40:53.000 --> 00:40:57.000
And as we move to the next slide, I want to emphasize this idea of language. Because I want, you know, you to leave this session thinking about what is it that you can do.

00:40:57.000 --> 00:41:04.000
You oftentimes we

00:41:04.000 --> 00:41:09.000
Think we need a coalition of the willing. We need all these people to get on board with this. But each of us as clinicians every day have the opportunity to do something different in terms of how we care for our patients.

00:41:09.000 --> 00:41:25.000
And so thinking about the language that we use, I saw several comments about the CDC. Most of us might think that when we tell our patients and we saw this a lot during the Covid-nineteen pandemic we would say oh the CDC says or these are the CDC recommendations.

00:41:25.000 --> 00:41:33.000
It's important to know that their entire groups of our population. Who could care less what the CDC says? Why?

00:41:33.000 --> 00:41:46.000
Because the CDC has done them wrong. Historically. And there are numerous events that occurred in which individuals still remember.

00:41:46.000 --> 00:42:04.000
And you can learn these from just talking to older adult patients who have lived through this and their families. I mean, whether it's the eugenics study, it the eugenics study did an end until the 19 seventys their individual older adult patients who lived through these experiences and it influences their decision-making.

00:42:04.000 --> 00:42:11.000
So patients like Mr. Willie Jenkins, their family members, they as individuals. May have lived through these experiences.

00:42:11.000 --> 00:42:15.000
So we think that when we're educating our patients and we're using this knowledge that we're opening up a world for them to feel better about and more trusting.

00:42:15.000 --> 00:42:30.000
When actually a baseline level of understanding about cultural experiences can change the way we care about our patients and it can help us to provide more person centered goal concordant care.

00:42:30.000 --> 00:42:31.000
And I'll stop there.

00:42:31.000 --> 00:42:36.000
Yes, thank you. So, feel free to put your questions. We've been getting a lot of questions, but if you have more questions, feel free to drop those in the chat where the QA.

00:42:36.000 --> 00:42:45.000
I see some already here. So I know to start, I just wanted to ask if Karen and Shrika could revisit that point about racism as trauma.

00:42:45.000 --> 00:42:56.000
We got a lot of questions or just comments about revisiting that point because it was a little the audio cut out a little bit.

00:42:56.000 --> 00:42:59.000
Karen, I'll let, yeah, I was gonna say, Karen, I'll let you revisit.

00:42:59.000 --> 00:43:09.000
I think something's going on with my, audio or internet.

00:43:09.000 --> 00:43:18.000
Okay, so I'll emphasize, the comments that have been said thus far is since the COVID-19 pandemic, our language is shifting.

00:43:18.000 --> 00:43:30.000
We're talking more about health equity and before we were focused on health disparities and sort of resting in a place of humility, in terms of recognizing that disparities exist.

00:43:30.000 --> 00:43:37.000
And now we've moved sort of along the continuum to talking about health equity. Help equity is more action oriented.

00:43:37.000 --> 00:43:44.000
So what can we do to balance some of this out? Now that we know and we recognize that there are significant disparities.

00:43:44.000 --> 00:43:50.000
We've all seen them unfold right in front of our eyes during the pandemic. So now what can we do to shift and create more equity?

00:43:50.000 --> 00:43:56.000
But the other thing that changed is that we were not talking about structural and systemic racism in the way that we are.

00:43:56.000 --> 00:44:01.000
And now that we've named it, we've seen it, we've labeled it.

00:44:01.000 --> 00:44:07.000
In the context of trauma, we need to be acknowledging that racism is traumatic. Anyone who experiences racism is experiencing trauma.

00:44:07.000 --> 00:44:25.000
If we were to go back to the slide and you'll have these slides, if you go back to the one that explains what is trauma and how we talked about it's an event or circumstances that influences one's capacity to have control over their decision making.

00:44:25.000 --> 00:44:32.000
Some people don't have control over their decision-making. There are many people who would rather live in an environment with clean water.

00:44:32.000 --> 00:44:35.000
But they're not in control of the water that's in their community and they don't have the option to just move to a place where water is cleaner.

00:44:35.000 --> 00:44:46.000
So as we focus on the social determinants of health. We spend a lot of time asking questions about social determinants of health.

00:44:46.000 --> 00:44:53.000
And then after we ask the questions. We don't really do anything with the information. Thank you for the slide.

00:44:53.000 --> 00:44:59.000
So we ask these questions as we're assessing social determinants of health, but then we rest in a place of cultural humility by saying I'm open, I'm curious, I wanted to know, but what can we do about it?

00:44:59.000 --> 00:45:13.000
And so this idea that trauma. Is that racism is traumatic. Can shift the way that we engage.

00:45:13.000 --> 00:45:19.000
Our clients, I'm sorry, and social worker clients in the health care or patients.

00:45:19.000 --> 00:45:28.000
Around these issues of the lasting adverse effects of these experiences. And how these experiences influence decision making. When a person is experiencing serious illness.

00:45:28.000 --> 00:45:33.000
Thank you so much and I did want to point out a few of the questions here in the chat box.

00:45:33.000 --> 00:45:53.000
There was one here. Are there any differences between those who experiences trauma as an adult versus as

00:45:53.000 --> 00:45:54.000
Field.

00:45:54.000 --> 00:46:03.000
So, yes, so the studies show that, a child who has that 1st year of your life.

00:46:03.000 --> 00:46:12.000
If you have a trauma experience during that 1st year of life, even if you have masterful therapy.

00:46:12.000 --> 00:46:24.000
They they tend to stay more traumatized than someone who experienced trauma after the 1st year with masterful therapy. So it's not necessarily.

00:46:24.000 --> 00:46:35.000
The what happened as much as when it happened because as you can imagine as a from from birth to to one you there's a lot of brain growth.

00:46:35.000 --> 00:46:39.000
There's a lot of imprinting about what the world and how the world operates for you at that age.

00:46:39.000 --> 00:46:40.000
And that can be hard to unwire once it's imprinted so early.

00:46:40.000 --> 00:46:53.000
Thank you so much. And there was another 1. 0, I'm sorry, Karen. There I just.

00:46:53.000 --> 00:46:54.000
Okay. No, it's just asking if there's another question to proceed.

00:46:54.000 --> 00:47:10.000
Yes, there was one here about documentation about do you ask the patient if you can document their replies to your questions regarding their history or admitted trauma.

00:47:10.000 --> 00:47:17.000
I don't I don't know if Karen does I don't ask for documentation only because it's like other things.

00:47:17.000 --> 00:47:29.000
Now I like saying that someone grew up in an alcoholic family, but as far as if we begin to do therapeutic which I do not do, which I do not offer in my practice.

00:47:29.000 --> 00:47:36.000
I think therapeutic treatment may be a different, thing because sometimes in behavioral health, there.

00:47:36.000 --> 00:47:43.000
Treatment plans are protected. But I as far as asking about ACEs and asking about trauma, I do not.

00:47:43.000 --> 00:48:02.000
And we now have DSMV 5. Codes for trauma. So I think it is something that is becoming commonplace so we can code forward and things like that and that's gonna inform other caregivers, other healthcare workers.

00:48:02.000 --> 00:48:14.000
And Sherri, I'd like to also add, I'm not sure if the question was related to the documentation and Chelsea, if you see the question, maybe you can tell me, but I think it's important for us to believe our patients when they tell us that they've had these experiences and so providing evidence or documentation of it is less important.

00:48:14.000 --> 00:48:17.000
Then being present with your patient and hearing and understanding how the event or the situation is impacting them. And health care.

00:48:17.000 --> 00:48:29.000
Yes, and yeah, I think the question was asking about if you're documenting their replies to your questions in your notes or in your, in your person, in your, in their medical record, I believe that was the.

00:48:29.000 --> 00:48:59.000
Specific ask and then I saw a couple of questions here also in the chat about how can we structurally support medical providers that are anxious about exploring trauma narratives and the risk of traumatization.

00:49:01.000 --> 00:49:12.000
One of the things I would add is if you have a social worker on your team, I can't speak for all social workers, but I work with many social workers and I think that social workers are.

00:49:12.000 --> 00:49:28.000
Especially good at engaging in assessments and we are well trained and credentialed to Do trauma assessments with patients, but also to engage patients and families in conversations about it.

00:49:28.000 --> 00:49:47.000
I think we are uniquely equipped with skills that enable us to do that. That doesn't address what can the physician do, but what I will say is if you have a social worker on your team, I would say look to social workers to provide leadership in the interest of the amount of time that we have left if we had more time I would list out some things but please have a social work on your team I'm sure most

00:49:47.000 --> 00:49:48.000
do, but we, we can provide leadership that can be essential in this area.

00:49:48.000 --> 00:49:49.000
And I was gonna say as a position, it's like any other thing that we collaborate with if I notice the patient has trauma and they're willing to work on it because I always ask patients once we.

00:49:49.000 --> 00:49:58.000
Evaluate the trauma and recognize it. I then ask them if they want to move forward with treatment or with discussion because everyone doesn't want to relive their trauma.

00:49:58.000 --> 00:50:08.000
So if they do, then. I will refer them to a social record therapist.

00:50:08.000 --> 00:50:14.000
Okay, thank you. I see another question about. Is it possible to overemphasize trauma in someone's life?

00:50:14.000 --> 00:50:21.000
Is there a way to ask in order to gauge the real impact of an ace in someone's lived existence?

00:50:21.000 --> 00:50:27.000
Well, I'll respond by saying I'm not sure what the person means by real, but when a patient tells me something, it's real.

00:50:27.000 --> 00:50:34.000
At least it's real for them and that's where I start with the. The patient in the family.

00:50:34.000 --> 00:50:53.000
But I do think that one can over emphasize that that's not where the patient wants to go or where the patient wants to spend time in a best possible world of care, you would have a relationship with the patient or you would establish rapport with the patient in which the patient would feel comfortable to share this.

00:50:53.000 --> 00:51:03.000
But even if the patient does respond affirmatively. And you have to use your best clinical judgment to engage a patient in a sensitive area.

00:51:03.000 --> 00:51:12.000
If the patient doesn't want talk about it, you shouldn't push. Further for the patient to talk about any aspect of the care.

00:51:12.000 --> 00:51:21.000
And so I think it's really important for the clinician to be very perceptive of the patient and understand whether this is an area that the person wants to export.

00:51:21.000 --> 00:51:26.000
They may tell you about it, but perhaps in this visit that's not where they want to go.

00:51:26.000 --> 00:51:27.000
Maybe they came in expecting something else to happen today and today's not the day that they want to go into detail.

00:51:27.000 --> 00:51:38.000
But yes, you can note it, you have a social worker follow up with him. You may be the social worker who's noting it and you might decide to follow up later.

00:51:38.000 --> 00:51:54.000
But I think you have to have a good read of your patient to know whether this is an area because you do run the risk of retraumatizing if you try to go into an area or go at a level that the person isn't prepared to engage with you.

00:51:54.000 --> 00:52:04.000
And I would say I would embed your palliative skills of having delivering difficult news, which we know part of Spikes is asking people if they're ready to talk about it.

00:52:04.000 --> 00:52:11.000
Is this the good setting? So just make sure you are always embedding the skills you already have as a palliative provider.

00:52:11.000 --> 00:52:20.000
Right, and you get that goes back to the note in this slide as well about understanding how the person prefers to have the conversation as you just said, as well.

00:52:20.000 --> 00:52:32.000
It's like the, how they want to communicate to what agree and what level. So thank you for that reminder.

00:52:32.000 --> 00:52:46.000
Okay, thank you. And we had another question here. Someone asking for a few examples or specific questions that you have naturally integrated into the assessment that reflect the trauma-informed care components.

00:52:46.000 --> 00:52:50.000
Well, I like what Sharika said early, not that I need to speak for you, Sharika.

00:52:50.000 --> 00:52:53.000
I really like the way and this is the way I would. Incorporated as well is while we're already asking questions to get to know our patient or to understand.

00:52:53.000 --> 00:53:05.000
What is important, whether that's when you're taking your medical history, but you're asking questions about family.

00:53:05.000 --> 00:53:16.000
Structure and functioning and historical experiences and That's a really great place, Asherika said, to incorporate it right in that as a part of the assessment.

00:53:16.000 --> 00:53:33.000
Tell me about your family. Tell me about the dynamics of that this person who you is engaged in your care or not, those kinds of like with Mr. Willie Jenkins, you know, talking with him about, you know, his brother and understanding the other people in his life, we could easily incorporate.

00:53:33.000 --> 00:53:39.000
The assessment tool into that discussion while we're talking about family and historical experiences.

00:53:39.000 --> 00:53:47.000
And you can also put it in your goals of care discussion. And I would. Kind of be sensitive like Karen said to the room.

00:53:47.000 --> 00:53:57.000
So if you see that it's emotionally high or the questions are causing a heightened emotion that I would say is now a good time to pause.

00:53:57.000 --> 00:54:03.000
You want to finish it later and I'll just be sensitive to breaking it up. Can you want me to follow back up with you in 2 days?

00:54:03.000 --> 00:54:09.000
Kind of get from the patient when they're ready. To have this discussion. It's kind of like our advanced directive discussions.

00:54:09.000 --> 00:54:15.000
We don't, we always tell Pete patients and families that this is a process, not an event.

00:54:15.000 --> 00:54:17.000
I think becoming trauma informed in your approaches are in the same vein. This is a process, not an event.

00:54:17.000 --> 00:54:31.000
And sometimes it may take a couple of sessions to get an understanding of what happened to someone. I also think it's important to be sensitive to your own stuff.

00:54:31.000 --> 00:54:40.000
Like I said, many of us, our own traumas and sometimes when a patient shares their experience, it pricks up against yours, right?

00:54:40.000 --> 00:54:48.000
So if you as a provider are feeling responsive to the patient stuff. You might have to pause yourself and I just give everyone permission to take the pause.

00:54:48.000 --> 00:55:05.000
There are times where I've been pricked with someone's trauma story. I was crying at 1 point and I just took myself a pause and went and sat down in my office to give myself a reprieve because sometimes people's story can prick us.

00:55:05.000 --> 00:55:07.000
We are all human.

00:55:07.000 --> 00:55:10.000
And Charika, I wanna just thank you before we wrap up for this emphasis on self-care because we talk a lot about self-care but then we don't give people permission to engage in self-care.

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And so if you're feeling as Sharika said, you need to take a moment in this work.

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I hope you're in a supportive environment where you could take a moment. And if you're a leader on a team, let's make sure that your team members feel that they can take a moment when they need to, especially if we're going to be the holder.

00:55:27.000 --> 00:55:38.000
Of these traumatic events. If we're gonna ask these questions and these questions as Sharika has said, things come up.

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There may be some moral distress when you're working with patients that have experienced trauma and you need to take care of yourself, engage in self-care.

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As well so that you can be at your best and providing the best possible care for your patients and families.

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You so much I did. We do have 2 more minutes. There was a question here. It says it seems the recording trauma history and medical records could re-traumatize or stigmatize patients who then have lost control of their story, who may see it or interpret it differently.

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Do you have suggestions for how to document answers to the trauma-informed care or ACEs questions?

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I see that as an institutional systemic resolution like I think, yes, we can document beautifully, but if we're not in a system that trained or knows how to execute trauma informed approaches know how to be sensitive to patients trauma stories because the talking about it in a demonstrative way automatically retraumatizes people.

00:56:44.000 --> 00:57:00.000
And so it's very important that we have systems that incorporate our biases, our implicit biases, because that's not I think what when I think about why someone would take someone's trauma story and then stigmatize them.

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I think that's a bias that they have, whether implicit or explicit. And we have to have systems that are prepared to address those types of behaviors at an organization system level.

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So that's why I was saying while this is about the patient provider, we also have to be aware that organization and system learning is just as vital to making this shift into the trauma-informed approach.

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That's what I think. Okay.

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Yeah, I'll just add quickly that I still appreciate this question because people do need to be careful of how they're documenting this question because people do need to be careful of how they're documenting information and records and we know, to be careful of how they're documenting information and records.

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And we know increasingly there's more literature and records. And we know increasingly there's more literature.

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You can search the medical literature and there's more literature, you can search the medical literature and there's more been written about the fact that that's more being written about the fact that that providers clinicians physicians in particular according to the literature tend to use physicians in particular according to the literature tend to use more, clinicians in particular according to the literature tend to use more stigmatizing language.

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You can start with.

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For certain populations than others. And so we do need to be mindful of how we're noting how we're documenting these.

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And it does require a skill set. And if you don't have this skill set, don't forge ahead until you get some.

00:58:00.000 --> 00:58:05.000
Sales to go along with this knowledge.

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Thank you so much to you both. A huge thank you to Dr. Bullock and Newman for this presentation.

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And thank you all for participating today. I've seen so many things in the chat and I just want to echo that.

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We will be posting the recording and the slides on Capsi's website under the on-demand webinars page, so feel free to revisit those and we'd love to hear your thoughts and feedback in the survey.

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And, suggestions for future topics. So, thank you so much.

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Thanks everyone. Thanks for participating. Bye bye. Thanks, Rika.

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Thank youI thinkBye. Thanks, Chelsea