Your SlideShare is downloading. ×
0
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
The A, B, C and D of Dignity Conserving Care
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

The A, B, C and D of Dignity Conserving Care

1,701

Published on

Presentation from the Integrating Wellness into Cancer Care Conference, 2008 by Harvey Max Chochinov …

Presentation from the Integrating Wellness into Cancer Care Conference, 2008 by Harvey Max Chochinov

Published in: Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
1,701
On Slideshare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
40
Comments
0
Likes
1
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide
  • People who are treated like they no longer matter will act and feel like they no longer matter. In other words, patients look at healthcare providers as they would a mirror, seeking a positive image of themselves and their continued sense of worth. In turn, healthcare providers need to be aware that their attitudes and assumptions will shape those all-important reflections.
  • Is a health worker more likely to assume intoxication in a confused, homeless patient, before considering whether they have a metabolic disorder?
  • Do people with chronic mental illness provoke assumptions about malingering or somatoform disorders, even before an appropriate medical examination has been done?
  • Might an assumption of poor quality of life in a patient with longstanding disabilities lead to the withholding of life sustaining choices?
  • Privacy; Support; Care Tenor
  • - Treat contact with patients as you would any potent and important clinical intervention ・ - Professional behaviours towards patients must always include respect and kindness ・ - Lack of curative options should never rationalise or justify a lack of ongoing patient contact
  • ・ Always ask the patient's permission to perform a physical examination - Although an examination may be part of routine care, it is rarely routine for the patient, so always, take time to set the patient at ease and show that you have some appreciation for what they are about to go through ("I know this might feel a bit uncomfortable"; "I'm sorry that we have to do this to you"; "I know this is an inconvenience"; "This should only hurt for a moment"; "Let me know if you feel we need to stop for any reason"; "This part of the examination is necessary because . . .") ・ Limit conversations with patients during an examination (aside from providing them with instruction or encouragement) until they have dressed or been covered appropriately
  • ・ Act in a manner that shows the patient that he or she has your full and complete attention ・ Always invite the patient to have someone from his or her support network present, particularly when you plan to discuss or disclose complex or "difficult" information ・ Personal issues should be raised in a setting that attempts to respect the patient's privacy ・ When speaking with the patient, try to be seated at a comfortable distance for conversation, at the patient's eye level when possible Given that illness can be overwhelming, offer patients and families repeated explanations as requested Present information to the patient using language that he or she will understand; never speak about the patient's condition within their hearing distance in terms that they will not be able to understand Always ask if the patient has any further questions and assure them that there will be other opportunities to pose questions as they arise
  • Roosevelt Sr. was a noted New York City philanthropist. He helped found the New York City Children's Aid Society, the Metropolitan Museum of Art , the American Museum of Natural History , and the New York Children's Orthopaedic Hospital. A participant in the dazzling New York society life, he was described by one historian as a man of both "good works and good times."
  • What history is chiefly about is life…things need not have happened as they did. Life in other times past was never on a track, any more than it is now or ever will be. The past after all is only another name for someone else’s present. How would things turn out: They knew no better than we know how things will turn out for us. (McCullough; Brave Companion p. xix). April 1865 Lincoln’s Funeral Procession in NYC
  • Twenty-sixth President of the United States , and a leader of the Republican Party and of the Progressive Movement . He became the youngest President in United States history at the age of 42. He served in many roles including Governor of New York , historian, naturalist, explorer, author, and soldier. Roosevelt is most famous for his personality: his energy, his vast range of interests and achievements, his model of masculinity, and his "cowboy" persona.
  • Elliott was unprepared for adulthood without his father's guidance and discipline and, despite his good intentions, adopted a life more defined by parties and alcohol than banking and real estate.
  • When Elliott Roosevelt married Anna Hall on December 1, 1883, he was more bon vivant than junior partner in a real estate firm and had begun battling the depression that would plague him for the rest of his life.
  • Anna Eleanor (1884-1962), Elliott Jr (1889-1893), and Gracie Hall (1891-1941). When Eleanor was eight, Anna Hall Roosevelt contracted diphtheria and died at age 29.
  • American political leader who used her influence as an active First Lady from 1933 to 1945 to promote the New Deal policies of her husband, President Franklin D. Roosevelt , as well as taking a prominent role as an advocate for civil rights .
  • Thirty-second President of the United States . Elected to four terms in office, he served from 1933 to 1945, and is the only U.S. president to have served more than two terms. A central figure of the 20th century during a time of worldwide economic crisis and world war, he has consistently been ranked as one of the three greatest U.S. presidents in scholarly surveys .
  • The picture of tranquility Yet, Eleanor had no template for loving, sustained parenting While they had 5 children, their marriage was highly conflicted, complex, and both parents were preoccupied with other ambitions and goals that helped shape the country Between the 5 Roosevelt children, there were 21 spouses
  • Less than two years after her mother’s death, Eleanor's father Elliott died on August 14, 1894 from a seizure after a failed suicide - he tried jumping out of a window - and the cumulative effects of alcoholism. He was 34 years old.
  • Healthcare providers have a profound influence on how patients experience illness and on their sense of dignity Dignity conserving care has an important effect on the experience of patienthood The A, B, C, and D of dignity conserving care ム attitude, behaviour, compassion, and dialogue ム provide a framework to guide healthcare practitioners towards maintaining patients' dignity This framework can be applied to teaching, clinical practice, and standards at undergraduate and postgraduate levels and across all medical subspecialties, multidisciplinary teams, and allied health professions
  • Transcript

    • 1. The A, B, C & D of Dignity Conserving Care Harvey Max Chochinov OM MD PhD FRSC Canada Research Chair in Palliative Care Director, Manitoba Palliative Care Research Unit Professor, Department of Psychiatry, Family Medicine and Community Health Sciences University of Manitoba, CancerCare Manitoba Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc .
    • 2. Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc
    • 3. Distribution of Sense of Dignity Responses Chochinov et al. Lancet. 1999;354:816-9 Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc
    • 4. Intact vs. Fractured Dignity:Psychological Variables <ul><li>Desire for death (p < 0.0014) </li></ul><ul><li>Loss of will to live (p < 0.013) </li></ul><ul><li>Depression (p < 0.0084) </li></ul><ul><li>Hopelessness (p < 0.020) </li></ul><ul><li>Anxiety (p < 0.003) </li></ul>Chochinov et al. Lancet. 1999;354:816-9 Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc
    • 5. Intact vs. Fractured Dignity:Physical Variables <ul><li>Pain (p < 0.048) </li></ul><ul><li>Difficulty with bowel functioning (p < 0.026) </li></ul><ul><li>Physical appearance (p < 0.002) </li></ul>Chochinov et al. Lancet. 1999;354:816-9 Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc
    • 6. Intact vs. Fractured Dignity:Dependency Issues <ul><li>Bathing (OR = 8.45 [1.50 to 47.70]; p < 0.016) </li></ul><ul><li>Dressing (OR = 2.79 [0.95 - 8.15]; p < 0.061) </li></ul><ul><li>Incontinence (OR = 3.47 [1.27 - 9.51]; p < 0.016) </li></ul>Chochinov et al. Lancet. 1999;354:816-9 Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc
    • 7. Intact vs. Fractured Dignity:Quality of Life Issues <ul><li>Quality of life ratings (p < 0.0096) </li></ul><ul><li>Quality of life satisfaction (p < 0.014) </li></ul>Chochinov et al. Lancet. 1999;354:816-9 Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc
    • 8. Dignity Model: L ogistic Regression Analysis <ul><li>Appearance (  2 =7.29; P<0.007) </li></ul><ul><li>Burden to others (  2 =8.28; P< 0.004) </li></ul><ul><li>Assistance with Bathing (  2 =4.09; </li></ul><ul><li>P< 0.05) </li></ul><ul><li>Present Pain Intensity (  2 =4.78; </li></ul><ul><li>P<0.03) </li></ul><ul><li>In vs. outpatient status (  2 =4.53; </li></ul><ul><li>P<0.04) </li></ul>Chochinov et al. Lancet. 1999;354:816-9 Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc
    • 9. Chochinov et al. Social Science and Medicine 2002 Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc
    • 10. Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc
    • 11. <ul><li>A: Attitude </li></ul><ul><li>Dignity Conserving Care </li></ul>Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc People who are treated like they no longer matter will act and feel like they no longer matter. In other words, patients look at healthcare providers as they would a mirror, seeking a positive image of themselves and their continued sense of worth. In turn, healthcare providers need to be aware that their attitudes and assumptions will shape those all-important reflections.
    • 12. Dignity Model Questions N=211 Chochinov HM, Krisjanson LJ, Hack TF, Hassard T, McClement S, Harlos M. Dignity in the terminally ill: revisited. J Palliat Med. 2006;9:666-72. Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc # Variable % Agree or strongly agree 1 thinking how life might end 41.7% 2 distressing symptoms 53.1% 3 uncertainly regarding illness 59.2% 4 feeling depressed or anxious 59.7% 5 feeling your privacy has been reduced 65.9% 6 changes in physical appearance 66.4% 7 not being able to accept things the way they are 71.6%
    • 13. Dignity Model Questions Chochinov HM, Krisjanson LJ, Hack TF, Hassard T, McClement S, Harlos M. Dignity in the terminally ill: revisited. J Palliat Med. 2006;9:666-72. Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc 8 not having a meaning spiritual life 73.7% 9 no longer feeling who you were 74.4% 10 not being able to mentally fight 74.5% 11 not being able to continue with usual routines 74.9% 12 feeling life no longer has meaning or purpose 75.1% 13 not being able to think clearly 77.3% 14 not being able to carry out important roles 78.5% 15 tasks of daily living 79.6%
    • 14. Dignity Model Questions Chochinov HM, Krisjanson LJ, Hack TF, Hassard T, McClement S, Harlos M. Dignity in the terminally ill: revisited. J Palliat Med. 2006;9:666-72. Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc 17 not feeling worthwhile or valued 81.4% 18 bodily functions 82.9% 19 not feeling you made a meaning or lasting contribution 83.3% 20 feeling you don't have control over your life 83.7% 21 feeling a burden to others 87.1% 22 not being treated with respect or understanding 87.1%
    • 15. Attitude… <ul><li>How would I be feeling in this patient’s situation? </li></ul><ul><li>What is leading me to make those conclusions? </li></ul><ul><li>Have I checked if my assumptions are accurate? </li></ul><ul><li>Am I aware how my attitudes affect patients? </li></ul><ul><li>Could my attitude towards the patient have something to do with me rather than the patient? </li></ul><ul><li>Do my attitudes enable or disenable my ability to establish open and empathic relationships with my patients? </li></ul>Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc
    • 16. Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc Is a health worker more likely to assume intoxication in a confused, homeless patient, before considering whether they have a metabolic disorder?
    • 17. Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc Do people with chronic mental illness provoke assumptions about malingering or somatoform disorders, even before an appropriate medical examination has been done?
    • 18. Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc Might an assumption of poor quality of life in a patient with longstanding disabilities lead to the withholding of life sustaining choices?
    • 19. B: Behavior Dignity Conserving Care Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc
    • 20. Chochinov et al. Social Science and Medicine 2002 Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc
    • 21. Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc <ul><li>Treat contact with patients as you would any potent and important clinical intervention </li></ul><ul><li>Professional behaviours towards patients must always include respect and kindness </li></ul><ul><li>Lack of curative options should never rationalise or justify a lack of ongoing patient contact </li></ul>
    • 22. Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc <ul><li>Always ask the patient's permission to perform a physical examination </li></ul><ul><li>Although an examination may be part of routine care, it is rarely routine for the patient, so always, take time to set the patient at ease and show that you have some appreciation for what they are about to go through (&quot;I know this might feel a bit uncomfortable&quot;; &quot;I'm sorry that we have to do this to you&quot;; &quot;I know this is an inconvenience&quot;; &quot;This should only hurt for a moment&quot;; &quot;Let me know if you feel we need to stop for any reason&quot;; &quot;This part of the examination is necessary because . . .&quot;) </li></ul><ul><li>Limit conversations with patients during an examination (aside from providing them with instruction or encouragement) until they have dressed or been covered appropriately </li></ul>
    • 23. Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc <ul><li>Act in a manner that shows the patient that he or she has your full and complete attention </li></ul><ul><li>Always invite the patient to have someone from his or her support network present, particularly when you plan to discuss or disclose complex or &quot;difficult&quot; information </li></ul><ul><li>Personal issues should be raised in a setting that attempts to respect the patient's privacy </li></ul><ul><li>When speaking with the patient, try to be seated at a comfortable distance for conversation, at the patient's eye level when possible </li></ul><ul><li>Given that illness can be overwhelming, offer patients and families repeated explanations as requested </li></ul><ul><li>Present information to the patient using language that he or she will understand; never speak about the patient's condition within their hearing distance in terms that they will not be able to understand </li></ul><ul><li>Always ask if the patient has any further questions and assure them that there will be other opportunities to pose questions as they arise </li></ul>
    • 24. C: Compassion Dignity Conserving Care Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc
    • 25. Compassion…. <ul><li>“ a deep awareness of the suffering of another, coupled with the wish to relieve it.” </li></ul>Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc
    • 26. Pathways to Compassion <ul><li>Humanities </li></ul><ul><ul><li>Literature </li></ul></ul><ul><ul><li>Philosophy </li></ul></ul><ul><ul><li>Ethics </li></ul></ul><ul><ul><li>History </li></ul></ul><ul><ul><li>Religion </li></ul></ul><ul><li>Social sciences </li></ul><ul><ul><li>Anthropology </li></ul></ul><ul><ul><li>Cultural studies </li></ul></ul><ul><ul><li>Psychology </li></ul></ul><ul><ul><li>Sociology </li></ul></ul><ul><li>The arts </li></ul><ul><ul><li>Literature </li></ul></ul><ul><ul><li>Theater </li></ul></ul><ul><ul><li>Film </li></ul></ul><ul><ul><li>Visual arts </li></ul></ul>Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc
    • 27. Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc Roosevelt Sr. was a noted New York City philanthropist. He helped found the New York City Children's Aid Society, the Metropolitan Museum of Art , the American Museum of Natural History , and the New York Children's Orthopaedic Hospital. A participant in the dazzling New York society life, he was described by one historian as a man of both &quot;good works and good times.&quot;
    • 28. Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc What history is chiefly about is life…things need not have happened as they did. Life in other times past was never on a track, any more than it is now or ever will be. The past after all is only another name for someone else’s present. How would things turn out: They knew no better than we know how things will turn out for us. (McCullough; Brave Companion p. xix). April 1865 Lincoln’s Funeral Procession in NYC
    • 29. Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc Twenty-sixth President of the United States , and a leader of the Republican Party and of the Progressive Movement . He became the youngest President in United States history at the age of 42. He served in many roles including Governor of New York , historian, naturalist, explorer, author, and soldier. Roosevelt is most famous for his personality: his energy, his vast range of interests and achievements, his model of masculinity, and his &quot;cowboy&quot; persona.
    • 30. Elliott was unprepared for adulthood without his father's guidance and discipline and, despite his good intentions, adopted a life more defined by parties and alcohol than banking and real estate. Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc
    • 31. When Elliott Roosevelt married Anna Hall on December 1, 1883, he was a more bon vivant junior partner in a real estate firm and had begun battling the depression that would plague him for the rest of his life. Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc
    • 32. Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc Anna Eleanor (1884-1962), Elliott Jr (1889-1893), and Gracie Hall (1891-1941). When Eleanor was eight, Anna Hall Roosevelt contracted diphtheria and died at age 29.
    • 33. Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc American political leader who used her influence as an active First Lady from 1933 to 1945 to promote the New Deal policies of her husband, President Franklin D. Roosevelt , as well as taking a prominent role as an advocate for civil rights .
    • 34. Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc Thirty-second President of the United States . Elected to four terms in office, he served from 1933 to 1945, and is the only U.S. president to have served more than two terms. A central figure of the 20th century during a time of worldwide economic crisis and world war, he has consistently been ranked as one of the three greatest U.S. presidents in scholarly surveys .
    • 35. Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc <ul><li>The picture of tranquility </li></ul><ul><li>Yet, Eleanor had no template for loving, sustained parenting </li></ul><ul><li>While they had 5 children, their marriage was highly conflicted, complex, and both parents were preoccupied with other ambitions and goals that helped shape the country </li></ul><ul><li>Between the 5 Roosevelt children, there were 21 spouses </li></ul>
    • 36. Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc
    • 37. Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc Less than two years after her mother’s death, Eleanor's father Elliott died on August 14, 1894 from a seizure after a failed suicide - he tried jumping out of a window - and the cumulative effects of alcoholism. He was 34 years old.
    • 38. Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc
    • 39. Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc
    • 40. D: Dialogue Dignity Conserving Care
    • 41. Dialogue: Acknowledge patient’s situation <ul><li>This must be so difficult </li></ul><ul><li>This must come as quite a shock </li></ul><ul><li>I’m so sorry to have to be telling you this </li></ul><ul><li>This is not the way I hoped things would go </li></ul>Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc
    • 42. Dialogue: Knowing the patient <ul><li>“ What should I know about you as a person to help me take the best care of you that I can?” </li></ul><ul><li>“ What are the things at this time in your life that are most important to you or that concern you most?” </li></ul><ul><li>“ Who else (and/or what else) will be affected by what’s happening with your health?” </li></ul><ul><li>“ Who should be here to help support you?” </li></ul><ul><li>“ Who else should we get involved at this point, to help support you through this difficult time?” (e.g. psychosocial services; group support; chaplaincy; complementary care specialists) </li></ul>Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc
    • 43. Dignity-Conserving Care A ttitude B ehavior C ompassion D ialogue Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc <ul><li>Healthcare providers have a profound influence on how patients experience illness and on their sense of dignity </li></ul><ul><li>Dignity conserving care has an important effect on the experience of patienthood </li></ul><ul><li>The A, B, C, and D of dignity conserving care , attitude, behaviour, compassion, and dialogue provide a framework to guide healthcare practitioners towards maintaining patients' dignity </li></ul><ul><li>This framework can be applied to teaching, clinical practice, and standards at undergraduate and postgraduate levels and across all medical subspecialties, multidisciplinary teams, and allied health professions </li></ul>

    ×