death has been with us for as long
as we have lived.
can we confront our own death as
we live?
Terri Schiavo suffered a cardiac
arrest at 26 yrs of age in 1990; as a result of this event Terri was diagnosed
as having irreversible brain injury. This injury left her unaware of her
environment, unable to communicate with or recognise her loved ones and
incapable of fulfilling the activities of daily life, including swallowing. As
a result of her brain damage she was fed through a PEG tube (a percutaneous,
entero-gastric tube). From that time controversy raged between her
husband-guardian and her parents with multiple legal and political
interventions about whether Terri was in a “persistent vegetative state” and
whether she should be allowed to die this would occur if the tube was removed.
It is alleged that Terri and her
husband had prior conversions about end-of-life planning, and, it was his
understanding that she would not have wished to continue to live in this way.
He sought to have the feeding tube removed commencing in 1998. On many
occasions the feeding tube was removed, to be replaced after further legal or
political intervention. The PEG was finally removed on
“WHO DECIDES?”
“Who
has the right to make life and death decisions for others?”
Who
has the right to consent to or refuse treatment for a current condition?
a
competent adult
If I become incompetent who will fulfil
MY treatment CHOICES?
in
the decision makers are
a guardian, & an Enduring
Power of Attorney (medical)
How have I come to this
topic?
I come to this topic as an Emergency Physician working in
a busy Emergency Department of a metropolitan, tertiary referral centre with a
background of socio-analytic learning with AiSA and a current PhD candidate of
Why explore this area –
vulnerability / autonomy?
At 0300 a cold, wet, winter’s morning
Metropolitan Ambulance Service notify the Emergency
Department from a N/H
96yr old lady is transferred by Intensive Care Ambulance -
for resuscitation.
On arrival - a frail little old lady, curled up on the
ambulance trolley
Desperately short of breathe, with gurgling respirations,
she is drowning in fluid
Hand over: bed-bound, demented, unable to communicate,
dependent in all activities
P/H: repeated episodes heart failure, recently
precipitated by a urinary infection
We could intervene, insert lines, tubes and monitor every
cardio-vascular parameter
We relieve her symptoms.
She dies with us, not with those she knows, those who have
been caring for her.
There is nothing familiar for her; visually, sounds,
smells, touch, temperature.
What is happening here?
Patients, entirely dependent, demented, bed-bound,
incontinent, assistance all ADLs
Transferred ED for resuscitation–is the expectation
restoration of good health
The patient will not recover from the underlying
condition: heart failure / lung dse
Quality of life will not improve, but continue to
deteriorate
What is the burden to the patient? / What is the benefit
to the patient?
My assumptions:
The emphasis is on quantity of life rather than quality of
life
Death is an unnatural event which must be avoided
Current medical management can ward off death
Fear of death - whose best interests are being served?
What is important here?
Deliberate before medical intervention occurs rather than
crisis intervention
Being mindful of the vulnerable
Respecting individual choice & Dignity in Death
The type of scenario is a regular occurrence.
How could this practice change?
What is end of life
planning?
End-of-Life Planning is a process that enables an
individual to develop an understanding of their medical condition with their
General Practitioner and then explore their own healthcare wishes with family,
friends and the medical practitioner with the intent that care at the end of
life reflects their personal values, objectives, religious and cultural needs
with in a legal framework.
The purpose for the process is to ensure that the
individual’s end-of-life plan has been made explicit to and with the person of
their choosing so that at a time when the individual is unable to communicate
their own wishes because of cognitive or neurological incapacity, a document
fulfilling the ethical and legal guidelines is available. These treatment
choices for end of life can then be realized respecting the autonomy of the
individual and honouring this individual’s determination.
The legal term for this person is Enduring Power of
Attorney (Medical).
“In
>> express
a preference for or against a particular form of treatment
>> make
right or responsible decisions regarding their treatment
>> provide
rational reasons for their decisions
>> recognise
decisions that are irrational or unwise, and
>> understand
all the major implications of a proposed course of treatment”
ALL ADULT Patients
= 1116: (20-99) yrs attending the Emergency Department
Clerical and Medical component of the questionnaire
Clerical: age,
sex, accommodation, referral pattern, ethnicity, religion, etc
|
CLERICAL DATA |
Variety |
Total |
Completed |
Incomplete |
|
Referred from |
8 |
1116 |
1113 |
3 |
|
Accommodation |
9 |
1116 |
1102 |
14 |
|
Country of Birth |
50 |
1116 |
1072 |
44 |
|
Culture |
48 |
1116 |
880 |
236 |
|
Religion |
22 |
1116 |
1033 |
83 |
Medical: reason
for attendance, admission, POA, ACP, EPOA (medical), etc
|
MEDICAL DATA |
Options |
Total |
Yes |
Incomplete |
|
Power of Attorney |
Yes/No |
1116 |
74 |
802 |
|
Enduring POA
(medical) |
Yes/No |
1116 |
40 |
802 |
|
Health Care Planning |
Family/GP/Aged Care/
Hosp |
1116 |
30 |
795 |
|
Advanced Care Plan |
Yes/No |
1116 |
6 |
807 |
NO, end of life planning is not occurring in this community!
Why not?
When I came to this research my plan was to work with the
General Practitioners of the Community in the setting of an Aged Care Facility.
I approached 2 significant aged care organizations to ask them to consider this
research.
Aged Care Organization
1
Speaking with the
Quality & Research Unit
We do not
believe the research is going in a direction we wish to pursue
We are
concerned about the method; in a business school?
We have a
“well” model of care
Our medical model is to defer to the decision maker.
Speaking with the CEO
of this organisation:
We are undergoing accreditation; we don’t have time or
resources.
Internal cultural issues,
relationship of staff to patients, maturity of staff
This is cutting edge research; how do we maintain control,
fear: emotional safety?
How do we manage the process of
patient’s being involved in decision making?
How do you raise these issues?
Aged Care Organization
2
We are a
conservative organization and this is controversial.
We do not
have the resources to do the work.
Regional Division of GP
meeting April 2003
We will
finance the time with the GPs; this research is important.
How many GPs do you wish to
interview? - (10-12) = 13
When do you
want to start? - as soon as possible =
organized by May 2003
GP questionnaire:
13 General Practitioners,
Demographics: Age:
(40-75)yrs, Sex: M=7, F=6,
Ethnicity: A/S,
Australian, Macedonian, Jewish, Sri Lankan, English, Indian-Finnish. Religion:
Catholic, Protestant, Jewish, Moslem, Atheist, Agnostic, CofE, None.
Yrs of practice:
(8-50), End of Life plan: +/- 4
Primary task of the GP, Dr-Patient relationship,
Education, Role, EPOA(Medical) etc
Society to the General Practitioner: KILL
Death!!
The Shorter Oxford English Dictionary defines society as
‘the system or mode of life adopted by a body of individuals for the purpose of
harmonious co-existence or for mutual benefit. The aggregate of persons living
together in a more or less ordered community, a number of persons associated
together by some common interest or purpose, united by a common vow, holding
the same belief or opinion, a collection of individuals composing a community
or living under the same organization or government.’ etc
Cultural Influences
Australian society for the General Practitioner will
encompass the community in which he lives and works with its traditions,
customs, mores and its inherent philosophy. This society includes the cultural
traditions that have become a part of the Australian way of life.
In questioning in this society, I am confronted by a
number of idiomatic phrases that have become the reality of the society, not
just a myth, or flight of fancy, but a norm, characteristics to be lived
by.
a fair go, let sleeping dogs lie
she’ll
be right mate, don’t
let the side down,
tomorrow’s
another day, just get on
with it
don’t rock the boat
This is the vernacular that comes with the Australian
culture, the ‘aussie’ who never gives in, the ‘aussie’ who does not show his
feelings? But this is also the ‘aussie’
who would prefer to silence the provocateur, “let sleeping dogs lie”. When
issues become too difficult, “she’ll be right mate”, “let sleeping dogs lie”
don’t create trouble. It is as though it is more important to do, than to
question – “just get on with it”. Even if this is getting on with life for
“tomorrow is another day”.
It is not possible to think or speak about our own dying
or death. For the General Practitioner to speak about a patient’s dying or
death would be confrontational; this must be avoided. In this mode of being the
anxiety and dread of dying and death are split off and a ritualistic process
and pattern of interacting is used “she’ll be right mate” in an attempt to
maintain a semblance of control and to contain the anxiety, fear and personal
panic.
It does not feel as though it is possible to live with
this fear of death as the enemy of life as a rational reality. Death is the
enemy – KILL death. As a society it can only be lived with if we, with an
unconscious defensive activity, reframe death, it becomes a myth, and, in
grandiose fantasy as omnipotent beings we can overcome death. Or we avoid death
by repression, it needs to be disregarded and denied, so it can no longer
create anxiety.
Hypothesis:
Generally speaking the
Australian society fears death; and the General Practitioner, as a member of
this society, is consciously and unconsciously influenced by the attitude of
society, he lives in this same fear, he wants to avoid and deny death and as a
consequence he may not take up his role and its attendant authority to
end-of-life plan with his patients.
Miller and Rice in 1975 wrote elaborating the issue of the
impact of societal values on the individual in an enterprise. This same aspect
applies to the General Practitioner working within the Community. The embedding
of this individual in the culture of society ensures he will exhibit the same
tenets of society.
“The human resources available for an enterprise come from
the society in which it is located. The members of the society create its
culture and hence bring to the enterprise in which they work the cultural
constraints of their society. Environmental constraints are therefore
inevitably built into enterprises and thus become part of the internal
culture.”[1]
ANGLO-SAXON BACKGROUND
These excerpts from the General Practitioner interviews
identify his impression of the feelings about dying and death of the Community
in which he works.
The Australian society is afraid, we fear death, we are
scared of it because we do not know, I do not mention it to patients because I
believe the patient would think I was saying they were about to die.
and,
We are terrified of death as a society, we do not want to
think about it, we can not talk about it, we can not be with death, we keep our
children away from it; it is very hard for people. I do not believe we want to
think about death and dying, it is not in out mind, there are no thoughts,
there is no conversation, and we do not know how to talk about death and dying.
and,
The Australian society does not deal with death & dying
it remains one of the great taboos. In the past we were fatalistic and more
accepting of the inevitable outcome but this has changed we have become more
secular and appear to be more afraid. This fear of the unknown is huge, the
fear of being alone, of a void or the sense of a bottomless pit. Some people
will say they are not afraid of death but of the process of dying.
There is also another change which is inexplicable which
is commented upon by this General Practitioner.
Why does this generation hide death and dying from
children, in previous generations the movies depict the time of death as a time
that the family gathers around the bedside of the ill person and the death is
acknowledged by all? Perhaps death was more common place and accepted by all,
the life span was shorter, there was not the technology, pharmacology and the
interventions of today. We are trying to delay and avoid dying and deny death.
As an individual, there was the potential to learn from
experience within the extended family, but our cultural patterns have changed
significantly, we have adopted living as a nuclear family, patterns of
emigration have also changed. Both of these can result in limited personal
exposure to the process of aging and illness. Death has become an uncommon
event it is unknown and therefore to be feared.
Gordon in writing about current social structures in
‘Dying and Creating’ states;
“There is the fact of the dramatic reduction of the family
unit. The extended family, which included grandparents, uncles, aunts, and
cousins, has now shrunk to the small unit of parents and their children. Add to
this the increase in social mobility and the housing of people in huge,
anonymous, urban clusters, which deprive the individual of a meaningful
neighbourhood group, and you get a society made up of people who have very few
emotional ties linking them to each other.
The rarity of such emotional ties then diminishes a
person’s possibility of being moved and affected by the loss of any of them.”[2]
This further limits personal learning about vulnerability,
loss and emotional pain.
Another aspect that also diminishes the need to
communicate thoughts and feelings is;
We make a lot of assumptions that the other person will be
thinking like I am therefore I do not need to ask.
MULTI-CULTURAL
INFLUENCE
But there is also acknowledgement of a change occurring
within this society because of the multi-cultural nature of the Australian
population. The General Practitioner can not make the assumption that the
individual patient will have the same set of cultural influences to guide his
behaviour.
But as stated by these General Practitioners,
Because we are a multi-cultural society dying and death
will be dealt with differently across the cultures, this can be confusing
because although I may appear to be Australian I may revert to my own cultural
upbringing at times of death and dying; there is a lot of ritual around it.
and,
As a multi-cultural society there are many aspects to our
societies dealing with death and dying.
Does not knowing how the individual will respond, the
multi-culturalism of
Sharp in his book ‘Living Our Dying’ states that;
“The problem in seeking comfort is, by doing so we cannot
look upon the here and now with openness… And if we are dedicated to comfort no
matter what, when we come up against pain of any kind, we are going to turn the
other way.”[3]
This is the setting of the General Practitioner in the
multi-cultural setting for as this excerpt states,
Some cultures have extreme fear.
Talking with the family group seems to allow the General
Practitioner to distance himself from the intimate relationship of the dyad.
Depersonalisation with separation from the feelings, allows the General
Practitioner to maintain a professional demeanour and defend against this fear.
Some ethnic groups have more difficulty, in all ethnic
groups it is much better to talk together with the family.
and
In some cultures ritual and
community support provides assistance.
PRIMARY TASK for the
General Practitioner:
The academic and regulatory body for General Practice in
Definition of General Practice in
The primary task of “General Practice is to provide
universal unreferred access to whole person medical care for individuals,
families and communities. General practice care means comprehensive,
coordinated and continuing medical care drawing on biomedical, psychological,
social and environmental understandings of health.”[5]
In our regulated, economically driven paradigm of health
care for today we are given an expansive and altruistic model of medical care
that encourages the General Practitioner to approach their specialty from an
holistic perspective, a notable model. To provide care that is accessible to
all, involves a concern for the whole person, an approach to patient care that
is integrated for the patient within the context of their own environment and
situation.
This definition communicates a quality of care that is
comprehensive and inclusive, a model of care that aids the integration of the
individual, their illness and their life’s processes within society, it
encourages the enrolling of the individual to the recognition and then
potential acceptance of an organised healthcare programme with continuity of
care that assists and works with the person within their own circumstances.
This definition, as is the care to be provided, is
generalized, universal, inclusive but not explicit. It does not lead the
General Practitioner into areas that require greater clarity and explication
but relies on the General Practitioner being observant and focused on the task
before him at the time to ravel the issues and implications for the individual
who is presenting. It does not give suggestions or guidelines to focus the
care. Much of the specific work of
General Practitioners requires significant emotional commitment from the
General Practitioner, with the potential for the General Practitioner to become
himself emotionally defended.
When it comes to interviewing the General Practitioner
about his attitude to end-of-life planning, for example, the answers are; he
has not considered this process for the chronically ill patient; he recognises
that it is an essential component of the primary
task but has not considered taking up this responsibility nor does he feel
enabled to perform this task because of time limitations or educational
limitations on his part.
A General Practitioner states,
I suppose I should be doing this really, it is just
another thing to add to everything else I should be doing.
How does the RACGP take up the ethical imperative of its
leadership role, to enable the General Practitioner to focus on a primary task that is inclusive of whole
person medical care? How does the General Practitioner take up his authority in
this primary task, apply his
theoretical knowledge, clinical expertise and be congruent in his relationship
with the individual to provide this comprehensive care and end of life
planning?
This working hypothesis attempts to explore a facet of the
relatedness between General Practitioner behaviour and the way the primary task has been formulated by the
RACGP.
Hypothesis:
Because there is no
clarity surrounding specific implementation issues associated with the primary
task defined by the Royal Australian College of General Practitioners, the
General Practitioner takes an individual stance and may not view end-of-life
planning as a component of their work – as part of the primary task.
This hypothesis was derived from the analysis of
interviews with the General Practitioners and I will demonstrate its validity
with excerpts from these interviews. In
using the phrase ‘lack of clarity’, I am referring to the necessity for further
associated explanation and description to guide the General Practitioner in
areas of care in which they may require support and endorsement, areas in which
guidelines may assist their practice. The lack of clarity in the definition of primary task as stated in the hypothesis
also leads the General Practitioner to take on an existential primary task, for his work reflects his own personal
values as he experiences life. The assumptions he then makes for the care of
his patient’s will reflect his priorities for patient care.
This General Practitioner simply takes up the definition
of RACGP when asked,
We are primarily responsible for
health care in the Community.
A more grandiose concept of the primary task of the General Practitioner!
A General Practitioner is someone who lets anyone walk in
the door with whatever they have got and you treat whatever, I accept all
people.
Or from the perspective of an existential primary task,
Assisting the individual on life’s
journey.
There are also components of the primary task that are not taken up because they are hated or
infiltrated and corrupted by defensive processes; the tasks that create too much distress to
fulfil them, like, end-of-life planning.
If I go to a home and have a discussion with a patient who
is nauseated and vomiting, it is much easier to deal with the physical
conditions, rather than have a conversation with someone who is dying as a
result of a terminal illness, this is a different form of counselling that does
not fit into things, I would find it hard to initiate this conversation and
then charge for it.
As Joseph Sharp so profoundly states,
“Fears explode into consciousness.[6]”
Another General Practitioner from another perspective
says,
Primarily the issue is immediacy, dealing with the current
medical or administrative problems; time is difficult, and the uncertainty and
unknown limits the conversation.
[At this time our conversation is crowded out by noise,
going on alongside; this makes me think of the personal noise, the fear, the
anxiety when discussing dying and death, the ‘unknown known’, that will be
going along inside.]
This quotation is stated in a context of the
doctor–patient relationship were the General Practitioner considers that the
important aspects that he brings to primary
task in his relationship with his patient are;
knowledge, expertise, experience, confidence and
reliability for their healthcare coordination and planning, someone to confide
in or discuss issues with, generally give people some opportunity to talk about
what is going on for them. I am prepared to be with them, sit and listen.
From the research data the General Practitioner identifies
priorities in his expertise to fulfil his role, theoretical knowledge and
clinical skills. In addition to these, the General Practitioner has the
expectation of providing the space for a patient to discuss issues of
importance. It may be that in providing this space the General Practitioner
assumes that the patient will confide and talk about what is going on for them.
However, this makes the General Practitioner a passive observer, listening not
initiating, not purposefully taking up the task of end-of-life planning.
Currently end-of-life planning is left to the practice of
the individual practitioner but there are numerous areas within medical
practice that could have a detailed framework developed to elaborate a
practical way of working. This applies particularly to areas that have not had
significant change in their management orientation over time, or when the
treatment options have been exhausted. It is in this situation that the
maintenance of a quality of life is of relevance for the individual with a
chronic illness, a terminal disease and the elderly.
These areas require the General Practitioner to encompass
the psychological, inclusive of emotional and social aspects of health, as
important to the continuing and complete care of the individual, and in so
doing, to incorporate end-of-life planning to enable the individual to
articulate their medical care wishes.
But, has the doctor the ability to be with the patient? In
saying this, I am asking is he able to access within himself the feelings
present as he listens to the individual, is he able to aid the patient to move
to a place of exploration as a consequence of being with the patient. Does the
General Practitioner feel he has the internal resources to be able to take up
this component of the primary task?
An alternative would be, does the General Practitioner
have a systematic process to guide the patient through end-of-life planning?
Or, is the doctor aware of his own feelings and fears and therefore moves away
from extending this conversation?
What about End of life Planning?
The emphasis is life not death we are trained to cure and death
is failure.
“Death is something to be avoided”.
This General Practitioner states it very clearly,
We don’t really think about end of life planning in
General Practice because you know as you are going along, you don’t really
think about planning for everybody’s death because you are so busy dealing with
the stuff to do with life.
The General Practitioners are afraid of entering an area
that is unknown where they consider they do not have the ability. They would
prefer the patient, the family or someone else to initiate this discussion.
This General Practitioner acknowledges the difficulties
experienced with the considering of end-of –life planning.
I do not make the opportunity to end-of-life plan with
patients, I am not confident, I have not been trained to explore an issue like
this with patients it is different from delivering bad news, I am afraid of
creating more anxiety in people by discussing morbid subjects, the patient may
question whether I am trying to tell them something, or is their death
inevitable, will I take away their hope.
Hypothesis:
The General Practitioner is unable to exercise the
authority consistent with his role and avoids communicating with patients about
significant life events including end of life planning because of its
complexity and ability to provoke a considerable level of anxiety which he
feels unable to contain.
These following representative comments from interviews
with General Practitioners, demonstrate the major difficulty they face in
envisaging a conversation with a patient about end-of-life planning.
I have never initiated a discussion about end-of-life
planning with a patient, I would want the patient to initiate this discussion,
but patients do not want to think about dying or address death, they only want
to be positive.
Or from another interview;
The patient would need to have a reason like a chronic or
terminal illness before I would have this conversation, something that would
give me permission, allow me.
This General Practitioner recognises the need to provide a
safe place to aid in the containment of the anxiety and emotional distress. The
acknowledgement of the special nature of the doctor-patient relationship
assists in the development of this safe place.
The importance of relationship to me means the provision
of a safe place to explore inner feelings, listening leading to personal
understanding, the ability to trust and grow to know someone over time, to have
a perspective knowing their context, what is going on in their life and that of
their family and to be able to support both.
But because there is no perception of personal safety for
the General Practitioner, in this conversation and the view that they will
cause distress for the individual patient and will not be able to contain the
distress, it is much safer not to initiate the discussion.
Menzies-Lyth while working in the hospital environment
states,
“Staff still find illness and death, anxiety and distress
terribly difficult to listen to and talk about with patients and relations.”[7]
This General Practitioner communicates the fear and
anxiety experienced in considering a conversation about dying and death, how
limiting and at times paralysing this fear is; fear of the unknown. In the
setting of significant emotional pain the doctor does not feel capable of
initiating a conversation to elicit the needs of the individual.
I was scared and afraid about having a conversation about
sickness and death. The fear about intruding into a personal area and not
knowing what to expect having never been there before, I was afraid of
intruding. I had not been involved in discussions about dying or death. I had
not thought about how to have a conversation about dying or death, let alone
having a conversation about end of life planning. I have never had a
conversation about end of life planning.
Krantz in writing about containment acknowledges the internal resources required by the
practitioner, the ability to provide a space to allow anxiety, pain and
confusion to exist without becoming overwhelmed by their intensity.
“The key element in enabling people to operate from the
depressive condition is containment – in the sense that contexts must exist
which can sustain the presence of potentially crippling anxieties, intense
psychic pain, and disorientating confusion without themselves either confirming
these experiences or collapsing in the face of them.”[8]
This General Practitioner recognises an alternative method
to attain a similar end point. He speaks of a systematic process to bridge the
chasm between thinking, feeling, and doing.
Even receiving this information before having this talk
together I recognize how fundamental this work is, that I do not do this work,
and that I do not have a systematic process to do this work, if end of life
planning has occurred at least the options have been explored. When it is
unplanned everything is a crisis.
Other General Practitioners align with this mode of
thinking of developing a system in association with a chronic or terminal
illness and as a format prior to initiating a discussion with the patient. This
would give the doctor a strategy, permission, to initiate the conversation. In
so doing it would depersonalise the setting and create a process, provide a
different space.
The patient would need to have a reason like a chronic or
terminal illness before I would have this conversation, something that would
give me permission, allow me. Respecting them and their needs would make this
conversation a little easier, empathy is important in this situation and
therefore if there is no relationship it would be more difficult.”
An alternative is to put the responsibility on the patient
or their family!
I have never considered initiating this discussion about
end-of-life planning myself, but perhaps it could be the patient or the family,
perhaps I could incorporate it into the discussion with the check up of a
chronic illness, I could have a pamphlet in the waiting room and ask the
patient to collect it on the way out to have a conversation next time.
How much does the practitioner put himself in the way of
knowing?
I do not know what Enduring Power of Attorney (medical)
EPOA is; I have had no association with this concept.
But there are General Practitioners who do see it as part
of their role who do take up the responsibility of end of life planning as a
process.
I explore their wishes by asking them a direct question
and they give an answer. I do not know
what they are thinking or feeling, I do not ask, I do not know their religion,
I do not ask, I do not know what society
thinks but there do not appear to be any specific cultural or religious issues,
I fulfil the process, I ask the questions. The way families are now days they
are reasonably isolated and therefore have very little contact with death, or
the elderly dying, it is their first time.
The majority of General Practitioners spoke freely about
the significance of the Doctor-Patient relationship and its relevance to
creating a freedom in communication, but not in the realms of end of life
planning.
The importance of relationship to me means the provision
of a safe place to explore inner feelings, listening leading to personal
understanding, the ability to trust and grow to know someone over time, to have
a perspective knowing their context, what is going on in their life and that of
their family and to be able to support both.
I have already used this quotation from one of the General
Practitioner’s who is able to take up end of life planning as a component of
primary task, he says,
To have this conversation is just part of being a GP; it
is part of treating the person, part of the continuity of care.
EDUCATION
The General Practitioner states that there has been no
specialized education or learning to achieve a way of being with his patient to
fulfil the requirements of end-of-life planning.
Does the training for the medical student cater for the
communication skills required to address issues of theoretical complexity or
technical intricacy? How does the medical student gain the competency to
discuss matters of personal privacy, psychological or emotional intensity and
subjects of existential significance?
This General Practitioner says,
The General Practitioners state that post-graduate
personal experiential learning is of significance. There is inadequate
theoretical and didactic education and from analysis of the interviews there
have been limited endeavours to achieve a dynamic experiential model for
learning in under-graduate or post-graduate medical education.
Individual contact with dying or death within the family
is an important personal educational experience.
Gordon in writing about medical education reflects on the
current status;
“It is natural that medicine will attract students who are
interested in the biomedical sciences…Unless they have adequate time for
reflection, such students may ultimately adopt a dogmatic of overly technical
approach to clinical practice, where every question has one correct answer.
They may fail to reflect on broader questions about the healthcare system or
their place in it. Recent research into the psychological wellbeing of recent
medical graduates found that rates of emotional exhaustion and
depersonalisation rose significantly during the intern year.”[9]
Hypothesis:
Personal experience
with terminal illness, dying or death of a significant family member or close
friend or a specialized, structured education involving the theoretical
concepts (to develop a process) to communicate about end of life planning is
necessary before a General Practitioner will take up the role to end of life
plan with a patient.
There is the potential to learn from experience within the
extended family but our cultural patterns have changed significantly, ease of
travel has altered patterns of emigration as well as the nuclear family means
there is limited exposure to the process of becoming old and infirm for the
individual. Death has become an unusual event and therefore un-natural event,
when it occurs it is the first contact with death for the members of the family
and therefore something new to be comprehended.
This General Practitioner comments on her own personal
learning,
I have had no personal contact with the death of a close
relative or friend. All of my relatives are (overseas); there is no immediate
family in
The only way to deal with issues of significance in the
professional capacity is to remove one’s self personally from the anxiety
provoking components of the conversation to depersonalise the setting and
become theoretical and technical in the communication.
But does this lack of training impact on the graduate
commencing his medical practice? Or, what support is there within the tertiary
establishment to facilitate learning while working?
As stated by this General Practitioner,
we are sausages pre-designed; communication has a problem-orientated
focus that is solution driven there is no emphasis on the importance of the
relationship.
Gordon has researched the medical education system in
“Recent research into the psychological wellbeing of recent
medical graduates found that rates of emotional exhaustion and
depersonalisation rose significantly during the intern year.”[10]
This echoes the comments of this General Practitioner
reflecting on his training as an under-graduate and then as an intern commencing
at a tertiary hospital.
There was no training in my undergraduate education about
communicating issues of significance, I started my medical career as a child
and blundered along making some terrible mistakes on the way in talking with
people. There was no learning in the hospital environment either, I would be
told to go of and tell a patient and their family a diagnosis without any
guidance or mentoring about how to give such significant information. I
remember being the designated person to speak with a patient and family in a
neurosurgical rotation; I recall feeling distant and removed from them in my
communication. At other times I recognised when I had blundered because people
recoiled from the conversation or changed the subject.
This General Practitioner will agree with the comment
above, he states;
There is no education as an undergraduate to communicate
about issues of significance this comes with personal practice. The GP training
programme was most influential to my learning, we did role plays in small
groups around difficult patients, and difficult situations, these were
facilitated by trainers and we were asked to explore our feelings about the
context and how we felt about the part we played.
Another outcome of the style of education within the
bio-science of medicine is of cure rather than care with the myth of
omniscience with omnipotence. This leaves the medical practitioner in a
paranoid-schizoid position, either of grandiosity with personal prowess or
vulnerability in failure associated with personal responsibility and guilt.
Hellman reflects on a doctor-patient relationship with a
terminally-ill patient; Medical education does not prepare doctors to deal with
death and dying. The emphasis of modern medicine is on cure. Accepting that
death is inevitable for a particular patient usually invokes a sense of
failure.”[11]
Even within the realm of the doctor-patient relationship,
the General Practitioner is not equipped to take up the authority of his
primary task to provide comprehensive whole person medical care inclusive of
end of life planning. Menzies-Lyth wrote about this as it related to the
nursing practice, the same applies in the medical environment.
The General Practitioner uses the social defence
mechanisms[12]
available to us all in Society, denial of death; he is able to cure, avoidance
of facing death until there is no alternative; death is on his door step.
Education is a limiting factor; I have not been exposed to
or learnt about how to end of life plan, or end of life planning is not a
defined component of the primary task.
These defences are constructed to eliminate the situation
that would precipitate the anxiety, doubt or uncertainty; silence the thought,
obliterate the task, don’t initiate the conversation and control the
relationship.
SO
how does the
GENERAL PRACTITIONER
face
DEATH
the
?? “UNKNOWN
KNOWN[13]” ??
Anton Obholzer defines
the “UNKNOWN KNOWN”
“By this I mean
individuals facing tasks on or over the time/conceptual horizon; tasks that can
somehow be envisaged but not emotionally grasped; tasks that can be thought
about and yet not adequately conceived. It is as if what is required is beyond
the make-up of the individual, and in order to master the task, psychic
elements have to be summoned that cause discomfort and emotional turbulence.
The natural inclination
is to reduce the “length” of one’s vision – keeping one’s head down as regards
the future, and perhaps carrying on as if nothing had happened or was about to
happen… It does require a particular inner-world balance of omnipotence and
sanity to say -- ”
“The best way to control the future
is to invent it”
can WE as individuals
face our own
DEATH?
in a NEW way
MAKE OUR CHOICES
KNOWN?
we all know the importance
of being there
when the person needs the help.”[14]
[1] Miller, E. J. & Rice, A. K. (1975)
‘Selections from: “Systems of Organization”’, in (eds) Coleman, A.D. & Harold Bexton, W. Group Relations
Reader 1, pge65.
[2] Gordon, R. (1978) Dying and Creating: A
Search for Meaning, pge8,
[3] Sharp, J. (1997) Living our Dying, pge115.
[4] RACGP Memorandum & Articles of
Association, adopted at 2004 AGM.
[5] RACGP (2004) Definition of General Practice
in
[6] Sharp, J. (1997)
Living our Dying, pge42.
[7] Menzies Lyth,
[8] Krantz, J.(1996) ‘Anxiety and the New Order’ in pge88
[9] Gordon, J. Medical humanities: to cure
sometimes, to relieve often, to comfort always. MJA 2005; 182: 5-8.
[10] Gordon, J. Medical humanities: to cure
sometimes, to relieve often, to comfort always. MJA 2005; 182: 5-8.
[11] Hellman, A. Narrative and illness: the
death of a doctor’s friend. MJA 2005; 182: 9-11.
[12] Menzies Lyth,
[13] Obholzer, A. (2001) ‘The Leader, the
Unconscious, and the Management of the Organisation’ in (eds) Gould, L. Stapley, L. & Stein, M. The
Systems Psychodynamics of Organizations, pge213-214.
[14] Menzies Lyth,