Trauma-Informed Care Part 1: Definitions and Screening #487

What Is Trauma?

Trauma can result from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life-threatening, and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being. ¹ Trauma can affect individuals, families, communities, and generations. While not all stressful events result in trauma, many, particularly from marginalized backgrounds, experience traumatic events recurringly. This Fast Fact will define trauma-informed care (TIC) and discuss best TIC screening practices in in patients with serious illness. Fast Fact #488 will provide more specifics on how to provide TIC in serious illness care settings.

Trauma and Serious Illness Care

Posttraumatic stress affects about a third of patients with cancer and up to 64% of patients with a life-threatening condition. ² Experts anticipate these estimates will continue to grow.^3–4 The invasive and life-threatening nature of the medical setting can trigger traumatic memories, leading to anxiety, hypervigilance, and dissociation.^5,6 These stressors can disrupt daily functioning, the clinician–patient encounter, illness-related symptoms, and also increase hospital lengths of stay.^3,7,8 Being trauma-informed does not mean presuming all patients have a history of trauma, but instead requires clinicians to anticipate the possibility that someone may demonstrate trauma-related symptoms from coping with traumatic experiences.

What Is TIC?

TIC is complex and has many tenets but is essentially a clinical framework and culture of practice for relating to people who have experienced trauma or other harmful experiences. ⁹ It acknowledges that clinicians need to be aware that trauma can significantly affect how patients and caregivers interact with clinical care settings. TIC encourages clinicians to ask, “What happened to this person?” rather than “What’s wrong with this person?” It provides tools to recognize trauma symptoms among our patients, and to respond in a ways that reduce further harm.

How Do You Screen for Trauma in Patients with Serious Illness?

Screening for trauma can be especially challenging for patients with serious illness, and universal screening is controversial given concerns for re-traumatizing patients by discussing a traumatic event during periods of high symptom burden and emotional distress.^10,11 Clinicians should not, however, be afraid to inquire about past traumatic events, especially because patients may not always recognize how their trauma history is impacting them in the present, and therefore may not provide this history unless directly asked. Of note, eliciting a detailed history of traumatic events (e.g., medical trauma, racism, community violence, trafficking, genocide, abuse) is not vital to providing TIC. The “Trauma History Questionnaire” is a validated, 24-item self-report measure utilizing yes/no questions to identify past events such as crime, general disaster, sexual assault, and physical assault. ¹² While this tool is primarily used for research, it has been utilized in clinical settings; however, its length can make it difficult to routinely administer in patients with serious illness. ¹³ Furthermore, there is no standard scoring method and there are questions about its cultural adaptability. ¹⁴ In lieu of completing this detailed screening, many experts recommend a brief, open-ended inquiry focused on exploring how to reduce trauma triggers in the health care space. Two recommended questions are below:

“Have you ever experienced anything that makes seeing a health care provider difficult or scary for you?”^15,16

Universal “Precautions” in TIC

Because of the difficulty of screening in the palliative care setting, the National Hospice and Palliative Care Organization recommends clinicians take a “universal precautions” approach that focuses on assuming a possibility of trauma in all patients (and family members) and looking for physical and emotional indicators of trauma symptoms, such as hypervigilance, agitation, dissociation, or difficulty engaging with care teams. ¹¹ When there is concern for trauma symptoms, a TIC approach (see part 2 of this Fast Fact) can reduce the risk of re-traumatization. ¹⁸ It is important to distinguish the TIC framework of care from longitudinal trauma psychotherapy provided by a trauma specialist, which is often outside the scope of generalist, palliative care, or hospice clinicians.