Psychologist Florence Vinit on Accompaniment, Teamwork and the Gift of Life
“Every new experience in palliative care, each new patient, each new family that you meet is different, and the experience of accompanying a person at the end of life is life changing.”
By Devon Phillips. After completing her PhD, Florence Vinit decided to return to university to do a one-year internship in psychosocial oncology at the MUHC. According to Florence, working as a psychologist with patients and their families at the end of life has been a privilege as well as a life changing experience, both personally and professionally. I met with Florence at the MUHC in Montreal, Quebec.
Q: I understand you are just completing your internship in psychosocial oncology. What is your main area of interest?
A: I am focusing on accompaniment and bereavement. This means follow up with people who have lost a relative. I am also working on the palliative care unit to support patients who are in the process of dying, and to support families when they are in crisis. Psychologists are part of a multidisciplinary team. It is also part of the role of the psychologist to support their team members. In palliative care, teamwork is essential.
Q: You mentioned support for families in crisis. What could a crisis situation at the end of life look like?
A: Sometimes a patient is deeply distressed and the relatives want to speak to someone. Perhaps the patient has just realized that he is dying. Maybe a relative has just realized that their loved one is dying and now that it’s clear, the person is in shock. Or, the demise of the person has taken place much faster than expected. The crisis could also be due to complications with pain and people are in distress as a result. Patients can become aggressive because of terminal delirium and the relatives can be in shock seeing that. Some people at the end of life, or their family members, also have mental health issues and the pain of losing someone can add additional distress. In a crisis, the psychologist, or possibly someone else on the multidisciplinary team, can help.
Q: Tell me about how the multidisciplinary team functions.
A: In private practice psychologists usually take care of people on their own. In palliative care you really work in collaboration with your team to support each other and to accompany the dying person in many different spheres: medical, pain management, psychological aspects, day-to-day nursing care. The issues we address as psychologists are related to the psychological state of the patient. We evaluate for total pain, and the results, for example, speak about the degree of anxiety and uncertainty, fear of being alone, and difficulty of detaching from family members. So while patients receive treatment for medical conditions, it is also important to consider their psychological state and to take a multidisciplinary approach to treat the patient optimally. I would say that the collaborative aspect is very important.
Q: Who is part of this multidisciplinary team?
A: We have meetings every week where all the team members involved in accompaniment - that is, the physicians, nurses, music therapist, psychologists, volunteer coordinator who offers support groups for bereavement, sometimes also the spiritual counsellor, meet to discuss patients who are newly admitted and share information that can help to support patients and families. Sometimes there are family issues, and other considerations that we need to know about to offer the best care.
Q: Tell me about the psychosocial internship program. What have been the greatest learning points for you?
A: This internship is very unique. It is a gift to be with people who are at the end of life. It is also a very existential experience as it places us with our own finiteness of being human beings who are going to die one day. Welcoming and accepting this is part of the work and a privilege. I now have a much greater appreciation about bereavement and all the work that is required after the death of a patient including helping those with normal grief who may come to us just for one or two sessions to learn about grieving, to the treatment of those with complicated grief.
Q: What is complicated grief?
A: Because of the death of the person close to them and their own particular history, the person with complicated grief is in a state of suffering that goes beyond the normal grieving process. In this case, grief presents as depression and trouble adapting because the symptoms are severe enough to impair day-to-day functioning. Psychological follow up is necessary to prevent the person from descending into depression and potential suicide ideation.
Q: How can people with complicated grief be helped?
A: Bereavement therapy provides support for people who are experiencing depression or anxiety. It helps them go through the grieving process and recover. Sometimes grief is complicated because of family issues, or because of what happened at the time of death. Were there complications? Was the patient distressed? So we revisit the illness and the time of death. We also have to figure out how they will reconstruct their identity now that their loved one is gone. What does it mean to live alone? Some people plan to share their retirement with their spouse but then that person dies. The future you thought you could give yourself is now changed. Work is also required to address depression and anxiety as well as to find a sense of meaning in your life. So the therapeutic approach is a combination of the examination of existential issues as well as dealing with practical issues such as the management of anxiety or sleep.
Q: What is the role of a psychologist with patients and their families at the end of life?
A: Psychologists can open a space to talk without judgment. Sometimes family members want the patient to stay strong and not feel or express their pain. Seeing a psychologist can offer a way to experience authentic feelings and to verbalize them, to express pain, uncertainty, even anger or injustice in the face of the illness or of death.
Q: Do psychologists have tools they use?
A: Psychologists utilize specific psychotherapeutic tools and they use their know-how to create a climate of security and trust with their patient. There are many approaches depending on the situation but they include tools for relaxation, to help change perspective, to manage anxiety and sleep disorders, to identify stress triggers; there are so many ways we can help people.
Q: It is encouraging to know that so much support can be offered to people at a time when they are most vulnerable. I imagine that many people do not know what to expect when they are accompanying a loved one at the end of life.
A: Yes definitely, and for the patient I think it’s the same because they often can’t or won’t speak openly with their families. They may not realize that they are going to die or they can’t face it. Each person is different so it is important to determine what is relevant for that particular patient. If he is anxious, we will conduct an evaluation to make sense of the anxiety. Is he afraid of death? What are his preoccupations for himself, for those close to him? We have to approach carefully, delicately, and determine what the patient wants to talk about. It may also not be about dying but about what has been meaningful in his life. It could be to share worries about what will happen to his family. There is no recipe.
Q: You are almost finished your year. What has the overall experience been like professionally and personally?
A: I am very grateful to have been here this past year. Every new experience in palliative care, each new patient, each new family that you meet is different, and the experience of accompanying a person at the end of life is life changing. The issues of grief, suffering and loss have made me reflect a lot about death, how we choose to live, and what is meaningful in life from a personal perspective. And from a professional point of view, it has been very valuable to accompany people through loss. Loss is a part of many aspects of life, not just end-of-life care, because loss is part of the human condition. So this internship has made me very sensitive to these issues.
Q: Did this internship program fulfill your goals? Did you obtain the skills you were looking for?
A: I would definitely recommend this program. It’s a unique experience in both personal and existential spheres. And it’s a unique clinical experience because of the broad range of accompaniment experiences, different types of patients and families in palliative care and in oncology, including patients who have serious illness who are referred to us but who are not at the end of life. They too need may need support. This translates into very good clinical training.
Q: Any issues or particular challenges in working in psychosocial oncology?
A: The recent issue of medical aid in dying is more and more significant as people are asking for this. We have to meet with patients who ask for this and also meet with the relatives.
Q: What is the impact of medical aid in dying in terms of the role of the psychologist?
A: For some family members, it is not easy to accept that the person close to them has requested medical aid in dying. Yes, there is a specific medical procedure in place, but there are also ethical and psychological issues to consider which are clinically relevant and for which there is not a lot of research.
Q: What are your observations so far? How do you find families as well as clinicians are managing with this?
A: We recently had a conference on the subject of medical aid in dying. We were asking ourselves: what is the role of the psychologist? I think it’s to address the existential aspect. This is not only about what I want or do not want because while the law gives access to the procedure, there are psychological aspects to consider. People have to go through a process to arrive at such a decision; the process is not linear. There are also existential questions: How do you accompany the person in accordance with the meaning they associate with this decision? How is this decision presented to family members? And for the family, being told the exact hour of the death of your loved one can be distressing, or on the contrary, relieve apprehension about the unknown. The patient may have been thinking about this for a while, but the family has not been on the same journey and so there are gaps that can create tension, anger, sadness. As well, this can be hard on the team, including the volunteers who are in shock to discover that the person they saw yesterday who was very much alive is now dead today. So there is work to be done to prevent complicated grief with those who accompany the dying, including team members. I think teamwork is important in all aspects of palliative care but it is very important in relation to medical aid in dying.
Q: Any last thoughts about your experience in palliative care?
A: I want people to remember the gift of life. Our life is precious. The people we have around us are not here forever, they can go at any time. We don’t want to waste time on things that don’t matter.