Introduction
Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), can lead to serious respiratory insufficiency and multiple organ failure through systemic inflammation [
1]. Already under stress from pandemic induced factors, family members come under an even greater psychological burden, on the loss of their close relatives. Healthcare workers who feel especially strong responsibility for the treatment of their severe cases of COVID-19 may lead to excessive empathic engagement in the care of patients. They could develop compassion fatigue; “feeling the traumatic experiences of others as if they were their own” [
2], as has been noted in healthcare professionals working in palliative care [
3].
Herein, we report our intervention for a physician who was engaged in the inpatient care of two patients with COVID-19; a man in his 40’s and his mother who was devastated by his death. We first describe the course of the patients and later present that of their doctor in a time-oriented manner.
Discussion
Mental health problems such as depression, anxiety, and insomnia have been reported among frontline healthcare workers (HCWs) during the COVID-19 epidemic [
4,
5]. Among the underlying psychological factors reported are fear of infection, empathic fatigue, and moral injury as representative examples [
6]. However, it is difficult to assess the overall impact of moral injury or compassion fatigue because they depend on individual-level variables. The term compassion fatigue is defined as stress resulting from exposure to a traumatized individual and is described as the convergence of secondary traumatic stress and cumulative burnout [
2]. To date, there have been some reports of elevated levels of compassion fatigue in mental health professionals and HCWs providing palliative care [
3,
7].
Concern about moral injury, another psychological concept, was raised in the early days of the epidemic of COVID-19. Fears were raised that HCWs might have a tendency to place excessive blame on themselves and other staff because of the unprecedented and unpredictable workload [
8].
In our case, the attending physician felt extreme psychological difficulty while observing the deteriorating mental and physical condition of patient 2, who had to confront not only the ultimate trauma of the sudden loss of her son, but also the exacerbation of her own physical condition. The doctor had presented self-condemnation based on the thought that she could have done more in her treatment of patient 1. Because of the combination of secondary trauma caused by empathy fatigue and excessive self-responsibility (referred to as moral injury), she was considered at imminent risk of burnout.
Our attending physician case also needs to be considered in the context of critical incident stress in disaster medicine. Critical incident stress refers to the range of emotional, mental and/or physical symptoms which cause disruption to behavior, or the ability to function either on scene or after a critical incident is over [
9]. Severity of critical incident stress is affected by personal interpretation of the event, perceived seriousness of the incident, the degree of exposure, and social support from colleagues and superior or support from the organization [
10]. Our female doctor case had multiple factors that are considered to be related to the severity of the incident. Her exposure to patient and family cases was significant in terms of the length of time, the extent of responsibility, and the depth of emotion because she was attending to these cases as the only their primary doctor. Prior literature has suggested that a comprehensive multifaceted approach to the management of acute stress related to a critical incident is recommended [
11]. In our hospital, a systematic approach was developed and carried out by hospital executive staff to improve her work situation, including the involvement of other residents as supplemental personnel to support her clinical practice in the ward, the reinforcement of medical team by support from other departments, and the emotional support provided to the physician by the executive and clinical staffs and a mental health specialist.
There appear to be several factors that make it difficult for the personnel involved to accept the death of patients by COVID-19: (1) although there is a wide range of course, most patients recover even if they develop severe respiratory failure. Therefore, in cases resulting in death, the sudden, unexpected passing may not give sufficient time for families and caregivers to process and accept the reality. (2) the isolation from the patient necessary in the treatment of COVID-19 makes it more difficult for relatives to have a sense of reality, compared to other diseases with which they can see changes in the patient’s condition face to face. For these reasons, the HCWs in charge of the care of patients who do not survive are at risk of suffering a tremendous psychological burden because they are also responsible for the family’s mental health care.
In order to prevent the burnout of HCWs, it is important to monitor them for symptoms such as psychological distress and levels of fatigue, in the context of individual experiences. It must also be noted that stress-related physical symptoms, such as gastrointestinal symptoms, pain, and appetite loss, have been reported to be increased in frontline HCWs during the peak of the COVID-19 epidemic [
10]. Mental health intervention for HCWs should include psychological education about the recognition of trauma and the need for self-care, followed by a comprehensive approach to release anxiety and reinforce self-confidence. Finally, in addition to keeping track of their workload and mental health symptoms, it is essential to share information with executives. When needed, it would be beneficial for HCWs to be provided with increased institutional support, such as by improving the medical team by enhancing manpower.
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