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

The A, B, C & D of Dignity The A, B, C & D of Dignity Conserving CareConserving Care

Harvey Max Chochinov OM MD PhD FRSC Canada Research Chair in Palliative Care

Director, Manitoba Palliative Care Research UnitProfessor, Department of Psychiatry, Family Medicine

and Community Health SciencesUniversity of Manitoba, CancerCare Manitoba

Published by Current Oncology and the Cancer Knowledge Network © 2011 Multimed Inc.

http://current-oncology.com/

http://multimed.current-oncology.com/

http://www.multi-med.com/

Distribution of Sense of Dignity ResponsesDistribution of Sense of Dignity ResponsesResponses Prevalence

0 No sense of lost dignity 114 (53%)

1 Minimal sense of lost dignity 64 (30%)

2 Mild; sense of lost dignity occasionally; regarded as minor problem

19 (9%)

3 Moderate sense of lost dignity; regards as significant problem

11 (5%)

4 Strong; feels clear sense of lost dignity most of time

5 (2%)

5 Severe; clear sense of lost dignity almost always present

0 (0%)

6 Extreme; sense of lost dignity virtually constant

0 (0%)

Chochinov et al. Lancet. 1999;354:816-9





Intact vs. FracturedIntact vs. FracturedDignity:Psychological VariablesDignity:Psychological Variables

• Desire for death (p < 0.0014)

• Loss of will to live (p < 0.013) • Depression (p < 0.0084)

• Hopelessness (p < 0.020)

• Anxiety (p < 0.003)






Intact vs. FracturedIntact vs. FracturedDignity:Physical VariablesDignity:Physical Variables

• Pain (p < 0.048)

• Difficulty with bowel functioning (p < 0.026)

• Physical appearance (p < 0.002)






Intact vs. FracturedIntact vs. FracturedDignity:Dependency IssuesDignity:Dependency Issues

• Bathing (OR = 8.45 [1.50 to 47.70]; p < 0.016)

• Dressing (OR = 2.79 [0.95 - 8.15]; p < 0.061)

• Incontinence (OR = 3.47 [1.27 - 9.51]; p < 0.016)






Intact vs. FracturedIntact vs. FracturedDignity:Quality of Life IssuesDignity:Quality of Life Issues

• Quality of life ratings (p < 0.0096)

• Quality of life satisfaction (p < 0.014)






Dignity Model: LDignity Model: Logistic Regression Analysisogistic Regression Analysis

• Appearance (2=7.29; P<0.007)

• Burden to others (2=8.28; P< 0.004)

• Assistance with Bathing (2=4.09; P< 0.05)

• Present Pain Intensity (2=4.78; P<0.03)

• In vs. outpatient status (2=4.53; P<0.04)






Chochinov et al. Social Science and Medicine 2002





A: AttitudeA: AttitudeDignity Conserving CareDignity Conserving Care


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.




# 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%

Dignity Model QuestionsDignity Model QuestionsN=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.





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%

Dignity Model QuestionsDignity Model Questions






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%

Dignity Model QuestionsDignity Model Questions






Attitude…Attitude…• How would I be feeling in this patient’s situation?

• What is leading me to make those conclusions?

• Have I checked if my assumptions are accurate?

• Am I aware how my attitudes affect patients?

• Could my attitude towards the patient have something to do with me rather than the patient?

• Do my attitudes enable or disenable my ability to establish open and empathic relationships with my patients?






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?




B: BehaviorB: BehaviorDignity Conserving CareDignity Conserving Care





Chochinov et al. Social Science and Medicine 2002






• 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




C: CompassionC: CompassionDignity Conserving CareDignity Conserving Care





Compassion….Compassion….

“a deep awareness of the suffering of another, coupled with the wish to relieve it.”





Pathways to CompassionPathways to Compassion• Humanities

– Literature– Philosophy– Ethics– History – Religion

• Social sciences– Anthropology– Cultural studies– Psychology– Sociology

• The arts– Literature– Theater– Film– Visual arts






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."




http://en.wikipedia.org/wiki/New_York_City

http://en.wikipedia.org/wiki/Metropolitan_Museum_of_Art

http://en.wikipedia.org/wiki/American_Museum_of_Natural_History


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.




http://en.wikipedia.org/wiki/President_of_the_United_States

http://en.wikipedia.org/wiki/History_of_the_United_States_Republican_Party

http://en.wikipedia.org/wiki/Progressivism

http://en.wikipedia.org/wiki/List_of_Governors_of_New_York

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 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.






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.




http://en.wikipedia.org/wiki/Eleanor_Roosevelt

http://en.wikipedia.org/wiki/Hall_Roosevelt

http://en.wikipedia.org/wiki/Diphtheria


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.




http://en.wikipedia.org/wiki/United_States

http://en.wikipedia.org/wiki/Politician

http://en.wikipedia.org/wiki/First_Lady_of_the_United_States

http://en.wikipedia.org/wiki/New_Deal

http://en.wikipedia.org/wiki/Franklin_D._Roosevelt

http://en.wikipedia.org/wiki/American_Civil_Rights_Movement_(1896-1954)


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.




http://en.wikipedia.org/wiki/President_of_the_United_States

http://en.wikipedia.org/wiki/Historical_rankings_of_United_States_Presidents


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.




D: Dialogue D: Dialogue Dignity Conserving CareDignity Conserving Care

Dialogue: Acknowledge patient’s situationDialogue: Acknowledge patient’s situation

• This must be so difficult• This must come as quite a shock• I’m so sorry to have to be telling you this• This is not the way I hoped things would go





Dialogue: Knowing the patientDialogue: Knowing the patient• “What should I know about you as a person to help me

take the best care of you that I can?”• “What are the things at this time in your life that are most

important to you or that concern you most?”• “Who else (and/or what else) will be affected by what’s

happening with your health?”• “Who should be here to help support you?” • “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)





Dignity-Conserving CareDignity-Conserving Care

Attitude

Behavior

Compassion

Dialogue


• 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, attitude, behaviour, compassion, and dialogue 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




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

Health & Medicine

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