Practitioners are implementing trauma-informed care in a variety of new care settings. “Women’s health was one of the first practice areas to implement this in response to sexual violence their patients had experienced that affected the way they later experience healthcare,” notes Joanna Hart, MD, MSHP, a pulmonary and critical care physician at the University of Pennsylvania.
The behavioral health field also recognized the need for trauma-informed care. “But trauma-informed care can be implemented across all clinical settings and specialties,” Hart says.
A group of trauma surgeons, ethicists, and violence recovery specialists offered recommendations for how surgeons can implement these concepts.1 “Consistent use of trauma-informed care in surgery is fairly uncommon,” says Gerard Vong, DPhil, one of the paper’s authors and director of the Master of Arts in Bioethics Program at Emory University.
Vong and colleagues explained the clinical and ethical importance of trauma-informed care in a way that is relatable and applicable to surgeons. Considering the evidence supporting trauma-informed care, Vong is hopeful there will be wider adoption. However, the necessary individual and institutional changes require education and resources.
Trauma-informed care “starts in the ambulance, to the trauma bay, operating room, ICU, inpatient unit, and even to patient discharge and beyond. Providing trauma-informed care even helps to reduce harm on trauma care providers,” says Tanya L. Zakrison, MD, MPH, FACS, FRCSC, another of the paper’s authors.
Ethicists are an important part of the multidisciplinary trauma care team. “Trauma is no longer just about suturing up gunshot wounds or holes in the aorta or solid organs or the heart,” adds Zakrison, director of critical trauma research at UChicago Medicine.
Surgeons may need to cut a trauma patient’s clothing, but what if the patient objects? Clinicians using the trauma-informed care approach would not forcefully override the patient unless the situation was truly emergent. Instead, the clinicians could explain why it is important to remove the clothing and offer to move to a more private space.
In that situation, if clinicians cut the patient’s clothing without consent, it damages the physician-patient relationship. “When that relationship is damaged, distrust can increase, thereby contributing to disagreements over prognosis and treatment,” Vong says.
Those disagreements can become heated quickly, leading to the need for an ethics consult. In that case, Vong says the ethicist’s response could include suggestions about how to repair the relationship. The ethicist also can suggest ways to prevent unnecessary violations of patient autonomy in the future through trauma-informed care. Vong says trauma-informed care can provide more sensitivity to the differential effects of the social determinants of health, better respect for patient autonomy, improved physician-patient and hospital-community relations, and lower risk of re-traumatization. “Trauma-informed care is relevant to all care settings. But it is most important in settings where patients are more likely to suffer from trauma,” Vong says.
To promote trauma-informed care, clinicians should better use the tenets of trauma-informed care. This means realizing the widespread effects of trauma; recognizing signs and symptoms; responding by including knowledge about trauma in policies, procedures, and practices; and avoiding retraumatization.2 “In doing so, clinicians will be more sensitive to the potential presence of prior trauma and the ways it can affect patients, patient care, and patient compliance,” Vong says.
Researchers should conduct rigorous studies on the use of trauma-informed care. Ethicists should help develop interprofessional curricula that teach the clinical and ethical importance of trauma-informed care.
“Ethicists are particularly well placed to do this, as they work interprofessionally across hospital units and are well attuned to the social factors that affect health and patient care,” Vong asserts.
Hart says when providers encounter a patient who is stressed, upset, or angry, the trauma-informed care approach focuses on the question “What has happened to you?” rather than “What is wrong with you?”
“Trauma-informed care can include everything from physical environments to communication strategies to even the way we perform clinical exams,” Hart says.
The goal is to be responsive to the needs of patients, families, and staff who have experienced trauma so they are physically and psychologically safe. In Hart’s view, the biggest change needed is better sharing of power with people who have experienced trauma. “When I am building an interpersonal relationship with a patient who has experienced trauma, I know the types of responses that might occur when that patient is stressed,” Hart says. These include behavior often viewed as “disruptive.” Rather than further diminishing the patient’s power or autonomy, providers practicing trauma-informed care strive to comfort and empower that person. Hart co-authored a paper on practicing trauma-informed care in the ICU.3
The ICU is a highly stressful environment with serious threats to patients’ health or survival, lack of sleep, noisy machines, many different clinicians coming in and out of rooms, and physical discomfort. “When a patient or family member in that environment has experienced prior trauma, predictable reactions would be to withdraw, avoid or be angry, and even yell at me as the ICU doctor,” Hart says.
Typically, this might result in restricting the family member from the ICU and maybe even calling security. “This further worsens the trauma of the experience,” Hart says.
In contrast, with a trauma-informed care approach, providers would interpret the “disruptive” behavior as a normal stress response, and find ways to support the traumatized person. That could mean connecting the person with social work or chaplaincy services, peer support, or reducing the stimulus of the ICU room (e.g., silencing alarms and interruptions) as much as possible. As for the role ethicists can play, the first step is to be able to recognize trauma.
During consults, ethicists also can use a trauma-informed care approach to facilitate communication. “Particularly after the last years of the pandemic, there has been collective trauma among clinicians in particular,” Hart notes.
For ethicists, understand the result of this trauma is a heightened stress response to situations that remind people of those experiences. “Educating clinicians on trauma-informed care principles and practices could be part of the recommendations to help resolve the conflict or improve the outcome,” Hart suggests.
One particular area of importance is recognizing that experiencing racism and other forms of discrimination is traumatic. People living in poverty are more likely to have experienced trauma.
“Ethicists should advocate within their institutions for trauma-informed care,” Hart argues. “Without this approach, existing healthcare disparities and inequitable treatment of people seeking care for themselves or their family members will be perpetuated.”
REFERENCES
1. Bliton JN, Zakrison TL, Vong G, et al. Ethical care of the traumatized: Conceptual introduction to trauma-informed care for surgeons and surgical residents. J Am Coll Surg 2022;234:1238-1247.
2. Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. July 2014.
3. Ashana DC, Lewis C, Hart JL. Dealing with “difficult” patients and families: Making a case for trauma-informed care in the intensive care unit. Ann Am Thorac Soc 2020;17:541-544.
Use the tenets of trauma-informed care by realizing the widespread effects of trauma; recognizing signs and symptoms; responding by including knowledge about trauma in policies, procedures, and practices; and avoiding retraumatization.
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