The goal of the present paper is simply to explore and describe the components of both the biomedical view and the holistic view of palliative care. Previous investigations into physicians’ perceptions of palliative care have often focussed on exploring educational interventions or testing knowledge. Scarce information has been collected regarding how the construct of palliative care is conceptualised from the clinicians’ perspective.
The perspective or worldview from which the physician approaches palliative care impacts on their behaviour. It is therefore important to understand these two disparate models as it relates to palliative care treatment.
The coining of the term “palliative care” is credited to Balfour Mount in 1973 and was originally used to describe patients with chronic or terminal illnesses. . However, despite its establishment there are still conflicting definitions, particularly in relation to the timing of palliative care. Doyle (2003, p. 10) remarked: “Seldom is a new service started anywhere in the world, or a new professional palliative care association formed, than people sit down and write a new definition.According to Kearney (1984, p.10) a worldview is a set of images and assumptions about the world” Kearney (1984) also referred to worldviews as “macro thoughts” or what social psychology, and cognitive psychologists call schemas- “subjective theories about how the social world operates” (Markus and Zajonc, 1985, p. 145).As stated by Vergil “mind moves matter.” In essence, people’s actions are best explained by the ideas they have in their head (Kearney, p.4). Thus, the worldview held by a clinician impacts on their practice of healthcare.
The biomedical model thus demands treatment of various parts with the ultimate goal of a cure. If success in this model is defined as cure, death is defined as ultimate failure to be aggressively avoided at all cost. Patients whose diseases cannot be “cured” are deemed as “untreatable” or “incurable”. Palliative care in this model is viewed as the port of last resort for those deemed beyond hope or waiting to die.
The management of illness is tailored to each person individual values and preferences. Thus a specific treatment is applied only if it is considered worthwhile from the patient’s perspective. The relationship between physician and patient is one of a partnership; it is an adult-adult relationship. This contrasts sharply with the hierarchical nature of the doctor-patient relationship in the biomedical model.
This research utilised data generated from Phase One of a jointly funded project on inappropriate admissions/treatment of patients with palliative care needs administered by researchers in the School of Nursing at the University of Auckland. The project received ethical approval from both Northern X and the relevant District Health Board (DHB). The research utilised a case study design in one New Zealand acute hospitalPhase One of the study included in-depth interviews with 7 physicians involved in generalist and specialist palliative care provision within an urban acute hospital to explore barriers to, and facilitators of, good palliative care management. The interview schedule included questions regarding experiences and views of palliative and end of life care provision within the DHB. Interviews were conducted at a location determined by the participant. The interviews were of approximately 45 minute duration and were audio-recorded with participant permission.
This research involved a mixed-method approach to data analysis. The analysis of collected of interview data involved looking at patterns of palliative care–related linguistic behaviour (word-use frequencies among participants representing the Biomedical-orientation and Holistic types). The transcripts of the 7 in-depth interviews were then compiled into two composite text files, based on classified type (i.e. Biomed and Holistic). This was accomplished using the Compare Vocabularies function of Hamlet (Brier, 2003) which identifies similarities in vocabulary usage between the texts by generating the percentage of overlaps of words present in the transcript files selected. Transcript files with similar word usage were then displayed using multidimensional scaling (Figure 1). A content analysis of this compiled text material (Biomedical or Holistic) was then accomplished with the HAMLET text analysis package (Brier, 2003), which was used to generate two separate lists (one for each worldview type) of words related to palliative care, based on counts of word frequencies within the two texts. Frequency of use was interpreted as a rough measure of the centrality or salience of a word to each of the two worldviews. A 50-word sample, based on the most frequently encountered “non-garbage” words (excluding articles, conjunctions, etc.), was drawn from the total generated word list, and word usage for each participant type, was then expressed as a percentage of the total words in the 50-word sample (to normalize across the two subsamples, which had different total word counts). Text quotes illustrative of both types were selected based on the results of the 50-word sample and Multidimensional scaling of the 35 words × 2 participant-types matrix, in both two and three dimensions, using WordProx (Powell, 2011).
.The majority of the participants were of New Zealand European ethnicity (5), one participant (1) listed ‘other European, while one participant (1) listed both a New Zealand European and Maori ethnic background. The physicians represented a number of specialisations including: emergency medicine, renal, colorectal, oncology, geriatrics and intensive medicine. The participants had all been employed full-time within the District Health Board for a time period ranging from 1 to 15 years. Only one participant listed some training in palliative care in the form of seminars. The majority stated that only” a little” of their workload consisted of palliative care provision (5) while two (2) participants stated that “a lot” of their workload involved palliative care services.
clinicians holding a worldview consistent with the Bio-medical worldview had a tendency to use terms related to death, illness, disease and medical treatments in comparison to those who held a more holistic view (Figure 4, Figure 5). The Biomedical worldview participants also included terms related to failure and symptom management.
Holistic participants on the other hand focused on life, the social world and a multidisciplinary approach
What follows are selected themes based on the frequently used terms related to both the Biomedical and Holistic worldviews as represented in the earlier analyses:In the first instance, the definitions of palliative care differed dramatically. Those clinicians from the biomedical perspective tended to see palliative care as equivalent to end of life care:In contrast clinicians from the holistic perspective held a broader view of the goals of palliative care:
Significantly, persons holding a biomedical view more frequently made reference to death and dying, whereas the holistic view participants more often made reference to life.
The idea of palliative care as an indicator of the ‘failure’ of treatment was also presented within the biomedical view:In contrast the view of holistic participants reflected the view that ‘fixing’ the patient was not the be all and end all of care:
there was also a focus within the biomedical view on the disease process whereas the holistic view sees the disease as one component of the person’s needs.
Although the word ‘’care” is used frequently by both perspectives, the meaning of the term varies. Within the biomedical model the word care is confined to a clinical meaning directed at symptom management while the holistic perspective can be viewed more broadly.
The appropriateness of treatment was also discussed. The two worldviews also varied sharply as to who was responsible for making the decision as to the appropriateness of care. Within the biomedical view the patient is held responsible for inappropriate treatment due to personal choice or a failure to plan, while within the holistic view appropriateness is the responsibility of the physician
The holistic view of health care has existed within the knowledge base of the medical profession since George Engel (1977) first laid out his alternative vision in the bio-psychosocial model. Since that time, the model has been successfully applied internationally to understand disease and its causes, improve public health as well as doctor-patient relationshipsHowever, as illustrated by the results, despite some shifts in view, a reluctance to adopt a more holistic view of healthcare still persists among physicians. These results are supported by a recent study conducted by Gott et al., (2011, p. 7) in both England and New Zealand which found that: Participants working in generalist palliative care settings still equated ‘palliative care’ with ‘terminal care’, despite the fact that in both countries, the much more wide ranging WHO definition has been adopted for over a decade.many possible explanations for this hesitance. In the first instance, while the holistic worldview considers the “whole person” including their social, psychological and spiritual needs as well as the interrelationships of these factors, the medical worldview has achieved its greatest successes by reductionism, At the level of the individual, among those participants from a biomedical view this was reflected in their understanding of their role as physicians. For these participants, there appeared to be a shifting of palliative care to the responsibility of others within the hospital setting. In other words, palliative care was not part of their job description it was the role of the palliative care ‘team’. Biomedical view participants saw their duties to sit squarely within the realm of curative medicine. There appeared to be a fundamental lack of acceptance that palliative care is a component of their work (Gott et al. 2011).
A shift in paradigm would require of the physician a much broader consideration of factors that impact on health and wellbeing, which would in turn require a greater investment of time and additional education on the part of the physician. Within the current medical system, time is money.
While some participants had embraced a more holistic approach to palliative care, those holding a biomedical view displayed attitudes which could create barriers to good palliative care delivery. As indicated in the text from the biomedical view example, the ‘failure’ of death was mentioned, as was an overall negative focus on death and dying within palliative care. 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. Limitations –The themes outlined above offer a small insight into the physicians’ understanding of palliative care. They also raise many issues for further research. However, given our small sample size we acknowledge that our participants’ views may not be typical of all physicians across New Zealand or at the hospital under study for that matter. The degree to which the views recorded provide an accurate picture of physicians’ worldview is unknown and the use of standard definitions by some participants to define palliative care may only reflect a voicing of accepted norms. Nevertheless our participants are likely to be typical of current clinicians, based on their admission of little or no formal training in palliative care.
Ultimately then a shift in paradigm requires greater effort not only at the level of the individual physician but at the level of healthcare systems. As recommended by Alonso (2004), 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. Challenging old attitudes and beliefs to the role of the clinician is a long term project. Further evaluative research into the best approaches to professional behavioural change with regard to palliative care would be beneficial (Hanratty, 2006
R Frey, Two ’worldviews’ of palliative care
Two “worldviews” of palliative care<br />Rosemary Frey<br />Lawrence Powell<br />Merryn Gott<br />Photo: Phillips (2011)<br />
Mensagitatmolem - The mind moves matter. –Vergil (BC 70-19)<br />Goal: <br />To explore and describe the components of both the biomedical view and the holistic view of palliative care. <br />
Definitions<br />Palliative – “to cloak” (OED, 2011)<br />Palliative care - originally used to describe patients with chronic or terminal illnesses (Balfour Mount)<br />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).<br />
Bio-Medical Worldview<br />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).<br />Art: Fundraw (2006)<br />
Holistic Worldview<br />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).<br />Photo: Travers (2011)<br />
Design and Sample<br />Case study design in one New Zealand acute hospital<br />In-depth interviews with 7 physicians involved in generalist and specialist palliative care provision <br />Topic: explore barriers to, and facilitators of, good palliative care management<br />
Data Analysis<br />Created two composite text files (Biomed/Holistic) using Hamlet (Brier, 2003)<br />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 <br />A Multidimensional scaling representation of the 35 words × 2 participant-types matrix, in two and three dimensions, usingWordProx(Powell, 2011) <br />Text quotes illustrative of both types were selected based on the results of the analyses.<br />
Definitions of Palliative Care<br />Biomedical<br />Holistic<br />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...<br />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.<br />
Life and Death<br />Biomedical<br />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.<br />Holistic<br />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. <br /> <br />
Treatment<br />Biomedical<br />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.<br />Holistic<br />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.<br />
Needs<br />Biomedical - symptoms<br />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.<br />Holistic – whole person<br />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. <br />
“Care or Caring”<br />Holistic <br />Biomedical<br />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.<br />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. <br />
Appropriate?<br />Biomedical – Failure to Plan<br />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.<br />Holistic - Physician Attitude<br />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’.<br />
Discussion<br />Why hesitance to change?<br />Success of medical reductionism – scientific advances in health<br />Lack of time – <br />Biomedical View Participant:<br />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.<br />
Discussion <br />Money matters – <br />Biomedical View Participant: <br />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.<br />
Recommendations<br />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.<br />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). <br />
Future<br />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) <br />Photo: Lily Holistic Centre (2011)<br />
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