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. Fast Fact #487 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: Post-traumatic 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, as well as 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 affect how patients and their caregivers interact with clinical care settings in significant ways. 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 way that reduces 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 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 healthcare 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)  
• “As people live with serious illness, they sometimes experience reminders of prior scary events. Has this happened to you?” (17).  

Universal “precautions” in TIC:  Because of the difficulty of screening in the palliative care setting, the National Hospice and Palliative Care Organization (NHPCO) 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.  

References: 

1. Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. 2014. https://store.samhsa.gov/sites/default/files/d7/priv/sma14-4884.pdf   
2. Bernard M, Poncin E, Althaus B, et al. Posttraumatic growth in palliative care patients and its associations with psychological distress and quality of life. Palliative & Supportive Care. 2022, 1-8.  
3. Center for the Study of Traumatic Stress (CSTS). Psychological effects of quarantine during the coronavirus outbreak: what healthcare providers need to know. 2020.     
   https://www.cstsonline.org/assets/media/documents/CSTS_FS_Psychological_Effects_Quarantine_During_Coronavirus_Outbreak_Providers.pdf 
4. Brown C, Peck S, Humphreys J, et al.  COVID-19 lessons: The alignment of palliative medicine and trauma-informed care. Journal of Pain and Symptom Management. 2020, 60(2): 26-30. 
5. Feldman, DB. Stepwise psychosocial palliative care: A new approach to the treatment of posttraumatic stress disorder at end of life. Journal of Social Work in End-of-Life and Palliative Care. 2017, 13: 113-133. 
6. Makoff, E. Racial trauma: A palliative care perspective. Journal of Palliative Medicine. 2020, 23(4), 577-578. 
7. Roth ML, St. Cyr K, Harle I, et al. Relationship between pain and posttraumatic stress symptoms in palliative care. Journal of Pain and Symptom Management. 2013, 46(2): 182-191.  
8. Von der Warth R, Hehn P, Wolff J, et al. Hospital costs associated with posttraumatic stress disorder in somatic patients: A retrospective study. Health Economics Review. 2020, 10(23): 1-8. 
9. Ricks-Aherne ES, Wallace CL, and Kusmaul N, Practice considerations for trauma-informed care at end of life. Journal of Social Work in End-of-Life & Palliative Care, 2020; 16(4):\313-329.  Trauma-Informed Care Implementation Resource Center  (https://www.traumainformedcare.chcs.org/resource/practice-considerations-for-trauma-informed-care-at-end-of-life/) 
10. Matchinger E, et al. From treatment to healing: Inquiry and response to recent and past trauma in adult health care. Women’s Health Issues. 2019, 97-102.  
11. National Hospice and Palliative Care Organization (NHPCO). Questions and answers about trauma-informed end-of-life care. 2020. https://www.nhpco.org/education/tools-and-resources/trauma-informed-end-of-life-care/. 
12. Hooper LH, Stockton P, Krupnick JL, et al. Development, Use, and Psychometric Properties of the Trauma History Questionnaire. Journal of Loss and Trauma 2011, 16:3, 258-283. 
13. Kubany E. S., Leisen MB., et al. Development and preliminary validation of a brief broad-spectrum measure of trauma exposure: The Traumatic Life Events Questionnaire. Psychological Assessment. 2000; 12(2):210–224. 
14. Gilmoor AR, Vallath S, Peters RMH, et al. Adapting the Trauma History Questionnaire for use in a population of homeless people with severe mental illness in Tamil Nadu, India: qualitative study. BJPsych Open. 2021 Jul 5;7(4):e122. 
15. Millstein JH. Becoming trauma-informed. Journal of General Internal Medicine. 2020, 35(7): 2199-2200.  
16. Garbitelli EC, Gerber MR, Williams PN, et al. “#218 Trauma-Informed Care with Megan Gerber MD”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list June 8, 2020. 
17. Meyerson JL, O’Malley KA, Obas CE, et al. Lived experience: A case-based review of trauma-informed hospice and palliative care at a Veterans Affairs Medical Center. American Journal of Hospice and Palliative Medicine. 2022; 40(3): 329-336. 
18. Wilson C, Pence D, and Conradi L. Trauma-informed care. The Encyclopedia of Social Work. 2013. https://oxfordre.com/socialwork/view/10.1093/acrefore/9780199975839.001.0001/acrefore-9780199975839-e-1063. Accessed April 4, 2022. 

Authors’ Affiliations: 1University of California, San Francisco (UCSF); 2Cedars-Sinai, Los Angeles, California; 3NYU Langone Health, New York, New York.
Conflicts of Interest:  None.