A Trauma-Informed Response to Working in Humanitarian Crises

This chapter addresses trauma experienced by individuals and teams working in humanitarian crises. It addresses causes of trauma and how these are unique to settings of international crisis, as well as many of the trauma-related syndromes that individuals may experience as a result. It also discusses interventions to lessen the impact of trauma, including brief and feasible interventions while providers and teams are in the field, as well as long-term interventions after a humanitarian crisis.

Noncommunicable Diseases in Crisis Regions

Noncommunicable diseases (NCDs) include a broad umbrella of illnesses that do not have an infectious etiology and usually need a chronic disease approach. Much of the challenge behind caring for patients with NCDs in resource-limited settings is the paradigm shift that many patients require from receiving medical care for acute illnesses to managing chronic illnesses. A few common NCDs are reviewed here—cardiomyopathies, dementia, cirrhosis, malignancies, and kidney disease. The etiologies and symptomatic management of each of these conditions in crisis regions are reviewed.

Skin Conditions in Crisis Areas

This chapter describes the most common and urgent skin issues facing palliative-medicine providers working in conflict zones, epidemics, and natural disasters. The first section focuses on exposure-related skin conditions, including burns, firearm injuries, frostbite, and snake bites. The second section describes lethal bacteria commonly found in floodwaters. The third section explores common skin conditions facing terminally and severely ill patients in crisis areas. The fourth section explains noninfectious yet potentially life-threatening skin diseases in these settings. The final section describes the opportunistic infections which could target patients with HIV anywhere.

Delirium and Acute Anxiety

This chapter reviews the assessment and management of patients presenting with acute confusion and agitation in humanitarian crises. The first section focuses on delirium, its distinguishing characteristics, and its diagnosis. The chapter then describes a contextually appropriate process for identifying and treating potentially reversible causes. Finally, it recommends management strategies for associated distressing symptoms with a priority on behavioral over pharmacological interventions. The second section addresses acute anxiety in the context of collective and personal trauma. Distinguishing features and manifestations are described. Approaches to management emphasizing behavioral and psychosocial care, with a limited role for pharmacological support, are outlined. The potential relationship of acute anxiety to other mental health conditions is also referenced.

Cultural, Psychological, and Spiritual Dimensions of Palliative Care in Humanitarian Crises

This chapter examines the complex psychological, sociocultural, and spiritual dynamics that arise when offering palliative care during humanitarian crises. It asserts the importance of being aware of one’s unconscious beliefs, biases, and assumptions, while advocating for cultural awareness, curiosity, and humility when engaging with those impacted by crises. It encourages readers to consider common dilemmas in cross-cultural caregiving situations. It also reviews factors that can increase psychological morbidities, stress resilience, principles of psychological first aid (PFA), and grief and bereavement, including a description of the types of loss people experience and how they may cope with grief. The chapter ends by discussing spirituality as a vital dimension of human experience, principles of spiritual first aid (SFA), and the essential accompanying that marks spiritual care in disaster situations.

Care of the Dying Patient

This chapter addresses the management of children and adults who are in the last hours or days of life, by providing details on the management of pain and other physical symptoms as well as suggestions for how to ensure psychosocial and spiritual support for the patient and their family. Providing palliative care during this time will not hasten death but is essential to ensure comfort and dignity for the patient. In the last hours and days of life, pain and other symptoms can be challenging to control. They may require frequent reassessment and rapidly escalating doses of medications.

Pain Management

Effective pain management plays a frequent and central role in palliative care, regardless of setting. This chapter addresses assessment of pain in both children and adults, as well as approaches to thoughtful and ongoing management of pain, including basic analgesics, opioid analgesics, adjuvant medications, and integrative therapies.

Practical Tips on Integrating Palliative Care

Palliative care has, historically, largely been absent or deprioritized in humanitarian emergencies. There is now increasing recognition of the need for it to be an integral part of any humanitarian response and, equally, for its integration to be routine across the many dimensions of a response. Such integration requires an understanding of the core principles and practice of humanitarian responses, and the structures of local, regional, and international agencies and their teams. The Sphere standards, now incorporating palliative care, comprise the fundamental standards and guidelines for humanitarian responses; they should provide key guidance for palliative care practitioners and organizations. Equally, the cluster system provides a structure for coordination of all the sectors in emergencies, and palliative care must be provided within this structure when it is in place for humanitarian events, whether acute or protracted. One core principle that humanitarian action increasingly incorporates is that of localization, whereby the response must recognize and respect local leadership and decision-making. This is equally true with emergency medical teams (EMTs), even when deploying internationally, because local responses have been overwhelmed. Finally, integration must incorporate all components of a robust palliative care response, including policy and guidance; community, primary, and specialist practitioners; training and mentorship; equipment, medication, and infrastructure appropriate for palliative care; and a referral system that uses both local and national structures.

Communicating Bad News

This chapter examines several strategies for conveying bad or challenging health-related news in a variety of situations. Principles discussed in this chapter are applicable to healthcare workers across all disciplines but are especially useful for palliative care providers and those working in humanitarian crises or emergencies. The SPIKES protocol and the Ask-Tell-Ask method communication tools are reviewed in detail with both positive and negative examples provided to aid the reader in application. Recommendations for setting up a family meeting, exploring patients’ goals, arranging follow-up, and responding to emotion are also included.

Essential Medicines

The concept of essential medicines (EM) was developed by the World Health Organization (WHO) to promote equitable access to safe, effective, and low-cost medicines. Access to EM is considered part of the right to health and is critical to the provision of palliative care. Access to EM is often disrupted in the setting of humanitarian crises, leading to further physical and psychological suffering. The recently published WHO document, Integrating Palliative Care and Symptom Relief into the Response to Humanitarian Emergencies and Crises, provides guidance on the prioritization and utilization of EM as part of an essential package of care. This chapter draws on the recommendations of the WHO as well as those of other expert committees and multilateral organizations. It provides an overview of commonly used medicines in palliative care and is applicable to the delivery of palliative care in humanitarian crises. It also provides general dosage guidelines.