Medical Matters:"One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient." - Francis Peabody
It was my first night on call as a trainee general practitioner attached to a rural practice in the northeast. I remember feeling a mixture of nervousness and anticipation; on the one hand looking forward to a night's sleep while at the same time hoping to be called out to break the ice of my first night "on".
The phone rang at 3am. It was from the family of a woman in her 70s who had advanced cancer. She was in some pain and quite breathless. Could I come out, please?
The car ate up the miles to the cottage which was situated on the edge of an old estate. A collection of cars outside told me the clan had gathered; I was led up narrow stairs to a bedroom.
There lay a gaunt and cachectic woman, lying quite still apart from a bubbling in her throat and the sound of laboured breathing as she tried to suck in whatever air she could. A quick examination confirmed that she was in severe pulmonary oedema (fluid on the lungs). I quickly drew up an injection of a diuretic, to get rid of excess fluid, followed by some morphine to ease her pain and distress.
While waiting for the drugs to work, I had a quiet word with her eldest daughter. Yes, the family knew and accepted that she was terminally ill. No, they were quite happy for her to remain at home, as long as I could make her comfortable.
She began to settle and was able to mumble a barely audible "thank you, doctor". I held her hand, while the family gathered round. While we talked about her life, she nodded or occasionally shook her head. Suddenly, she gripped my hand quite tightly and her eyes closed. Her breathing became shallow but was no longer laboured. She remained like this for another 40 minutes or so; then, with a loosening of her grip and a sigh, she passed away peacefully.
After a cup of tea downstairs, I headed off home. It was nearly 6am and too late to go back to bed. It struck me that while I had pronounced people dead during my hospital training, this was the first time I had held a dying patient's hand.
The memory came flooding back while reading an article on dignity and the essence of medicine in this week's British Medical Journal. The Canadian author, Harvey Chochinov, is concerned that kindness, humanity and respect are too often overlooked in the time-pressured culture of modern healthcare. And dignity, the state of being worthy of honour or respect, is becoming harder to achieve in the target- orientated health service of the 21st century.
In response, Chochinov has come up with a practical way to help healthcare workers achieve what he terms "dignity conserving care". Adapting the well known mnemonic airways, breathing, circulation (ABC) - drilled into first aiders to guide their immediate response to a medical emergency - the Canadian professor has developed an ABCD framework for dignity conserving care. Easy to remember and understand, ABCD stands for attitude, behaviour, compassion and dialogue.
Attitude emphasises the need for healthcare providers to examine their attitudes and assumptions towards patients. "People who are treated like they no longer matter will act and feel like they no longer matter," Chochinov notes.
The B in the mnemonic is about modifying our behaviour in order to help preserve a patient's dignity. Including kindness and respect in our behaviour towards patients is one example of a helpful behaviour.
Compassion, a deep awareness of the suffering of another coupled with a wish to relieve it, means acknowledging health professionals' own feelings. Training in patient narrative and the arts are essential to understanding the pathos of human illness.
The D of dignity conserving care - dialogue - means using phrases that respect the patient's unique situation such as "this must be frightening for you" or "I can only imagine what you must be going through". Tight budgets and performance targets often mitigate against the time needed to have a meaningful dialogue with patients.
The Irish Hospice Foundation has recently embarked on an important initiative that resonates with the ABCD concept. A €10 million hospice friendly hospitals programme aims to change the culture of dying in our hospitals.
One of the scheme's development co-ordinators is Paul Murray, formerly deputy news editor of The Irish Timesand former head of communications at Age Action Ireland.
Pointing out that 60 per cent of the 30,000 people who die in the Republic each year do so in hospitals, Murray says: "For the next five years we will be helping hospitals to take on board issues such as integrated care, communication, dignity and design as well as patient autonomy."
Hospice values also apply to people who are not dying. Chochinov's mnemonic will remind practitioners of the importance of caring about, as well as caring for, their patients.
Dr Houston is pleased to hear from readers at mhouston@irish-times.ie but regrets he is unable to reply to individual medical queries.
