R Frey, Two ’worldviews’ of palliative carePresentation Transcript
Two “worldviews” of palliative care Rosemary Frey Lawrence Powell Merryn Gott Photo: Phillips (2011)
Mensagitatmolem - The mind moves matter. –Vergil (BC 70-19) Goal: To explore and describe the components of both the biomedical view and the holistic view of palliative care.
Definitions Palliative – “to cloak” (OED, 2011) Palliative care - originally used to describe patients with chronic or terminal illnesses (Balfour Mount) Worldview - A more or less internally consistent set of orientations to the social world—encompassing cognitive, affective, and normative perceptual predispositions (Frey & Powell, 2005, p. 119).
Bio-Medical Worldview Its way of thinking is distinctly analytical and rationalistic. Clinical concerns are approached as puzzles to be solved; clinical encounters are treated as occasions for scientific inquiry. Because the object of analysis is the disease and not the patient, symptoms are treated as clues to diagnosis, instead of phenomena that are themselves worthy of treatment (Fox, 1997, p. 761). Art: Fundraw (2006)
Holistic Worldview Whereas the biomedical model is primarily analytical, the holistic model is as much hermeneutic as it is analytical. Ideally, understanding total pain thus requires entering the patient’s psyche, history, culture, beliefs, and social relations. This means not only observing but also asking about and interpreting the meaning of what she or he has lived through (Mino & Lert, 2005, p. 228). Photo: Travers (2011)
Design and Sample Case study design in one New Zealand acute hospital In-depth interviews with 7 physicians involved in generalist and specialist palliative care provision Topic: explore barriers to, and facilitators of, good palliative care management
Data Analysis Created two composite text files (Biomed/Holistic) using Hamlet (Brier, 2003) A 50-word sample of most frequently used words drawn: word usage for each participant type (Biomed/Holistic), was expressed as a percentage of the total words in the 50-word sample A Multidimensional scaling representation of the 35 words × 2 participant-types matrix, in two and three dimensions, usingWordProx(Powell, 2011) Text quotes illustrative of both types were selected based on the results of the analyses.
Definitions of Palliative Care Biomedical Holistic No, it's not the end of their life – Well that’s the paradigm which people have, I think, become constrained to by the use of these words, that these two issues are temporarily separated. That we have treatment and then we have, uh-oh, it's all failing, the patient’s dying, now let’s have palliation or end of life....And therefore if you think of something which needs to go on simultaneously with active treatment... Palliative care is care for the patient whose disease is not curable, so the patient will die from the results of the disease and it’s futile to attempt or to have the illusion of fixing that particular problem.
Life and Death Biomedical We stop people dying of vascular deaths and then they go on and die of worse things really. I mean there’s something not too bad about a big heart attack or a big stroke that kills you relatively quickly rather than dragging it out and having a slow painful cancer death. Holistic A lot of patients with what we might have thought of as inexorably fatal malignant conditions often live for many, many years in good health whilst receiving intensive treatments of various kinds.
Treatment Biomedical No, I can’t have a patient who dies, my patients don’t die, you know? I’m exaggerating but there is that sort of thing. And some people are, you know, they’re uncomfortable or feel inadequate if the patient doesn’t have a course of treatment that makes them better. You know, they feel that they might have failed. Holistic Once you’re in the emergency room the YUHAFTI syndrome starts – you have to do everything... But in fact whether you can or can’t fix it is irrelevant to whether or not you should or should not fix it. And that moral question is never considered.
Needs Biomedical - symptoms So that they’re still continuing with an active treatment but have got some other condition which is causing them ongoing pain or discomfort or some other symptom. For instance they might have peripheral vascular disease which might be untreatable so they’ve got ischemic pain or ulcers on their legs or might’ve had a stroke or ongoing angina or a cancer or something. Holistic – whole person The doctor has to bring not just their technical skills but they must bring humanity to that person as a human being. Therefore you have to get involved in matters of the nuances of illness as being a threat to their survival and as a threat to their wellbeing and quality of life, and you have to acknowledge those things and maybe address that.
“Care or Caring” Holistic Biomedical At the present time we have this archaic model where patients with complex multi-disciplinary problems are admitted under the care of what we call SOD, Single Organ Doctor, who focuses on the single organ, not even the patient. And not even, nothing remotely like their palliative or comfort care needs. So we would try to set that up beforehand, so I guess that’s end of life care-planning or advanced care planning and then the actual active palliative part might be much later down the line.
Appropriate? Biomedical – Failure to Plan They just waited for a crisis to happen and then they’d all pitch up in the hospital…other people who come inappropriately because there’s not a plan sorted out because it hasn’t been addressed by their teams and a lot of people are in that situation. Holistic - Physician Attitude Doctors are very reluctant to give appropriate professional recommendations anymore. ‘Oh I don't do that, I just lay out the options like an a la carte menu and then you tick, do you want the fries, do you want the garammasala, whatever you like. You pick, I'll just do it’.
Discussion Why hesitance to change? Success of medical reductionism – scientific advances in health Lack of time – Biomedical View Participant: I mean I'd like to have lots of training in lots of different areas but it’s the practical issue of can I do it. I'd like to know about the resources but I probably don't want to spend a lot of time doing it. I mean I have to do my own job.
Discussion Money matters – Biomedical View Participant: And if an item is reimbursable, then it's an appropriate way to spend time. If an item such as family discussion, end of life care family discussion, might take 45 minutes of a patient care interview, well during that 45 minutes I could’ve done three 15-minute billable procedures.
Recommendations Attitudes, beliefs, and self-perceptions underpin behaviour and thus practice. Therefore the worldview held by a clinician may either support or create barriers to holistic care. Hospitals also need to provide a context and resources, such as additional communication training, appropriate settings as well as personnel to facilitate a more holistic approach to medical practice Alonso (2004).
Future To hold together in one and the same medical act both the reductivist scientific truths that are so beneficial and also the larger truths about the patient as a human person is the really enormous challenge health care faces today (Sulmasy, 2002, p. 25) Photo: Lily Holistic Centre (2011)
References Alonso, Y. (2004). The biopsychosocial model in medical research: the evolution of the health concept over the last two decades. Patient Education and Counseling, 53, 239-244. Brier, A. (2003). Analysis of joint frequencies of words in a text. Southampton.UK: University Computing Service. Fox, E. (1997). Predominance of the curative model of medical care: A residual problem. JAMA 278(9), 761-763. Frey, R.A. & Powell, L.A. (2005). Beyond left-right ideology in the study of justice perception: Interdependent and independent distributive worldviews in Jamaica and New Zealand Journal of Cross-Cultural Psychology 36(1), 117-146. Fundraw (2006). “Caduceus” Retrieved from: www.fundraw.com/clipart/clip-art/2327/Caduceus/ Lily Holistic Centre (2011). “Reike” Retrieved from: www.lilyholistic.com/reiki_i0f2.png Mino, J. C. & Lert, F. (2005). Beyond the biomedical model: Palliative care and it’s holistic model. HEC Forum, 17(3), 227-236. Oxford English Dictionary (OED) (2011). “palliative.” Retrieved from: http://oxforddictionaries.com/definition/palliative Phillips, D. (2011). “Worldview” Retrieved from: wdavidphillips.com Powell. L. (2011). WordProx. [computer software]. Auckland: University of Auckland Sulmasy, D. (2002). A biopsychosocial-spiritual model for the care of patients at the end of life. The Gerontologist, 42(iii), 24-33. Travers, M. (2011) . Image #101725, Illustrator #0111 . Retrieved from: http://ClipartOf.com/101725