Two ’worldviews’ of palliative care
description
Transcript of Two ’worldviews’ of palliative care
Rosemary Frey
Lawrence Powell
Merryn GottPhoto: 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.
Demographics
• Gender: 6 male, 1 female • Specialities :
Age
Lowest
to 39
1
40-49 3
50-59 2
60 and
over
1
Emergency
Colorectal
1
Intensivist
1
Oncology
1
Renal
1
Geriatrics
1
Emergency Med
1
House Officer
1
Biomedical Worldview Participant
Holistic Worldview Participant
Definitions of Palliative Care
Biomedical
• 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.
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...
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.
NeedsBiomedical - 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”Biomedical
• 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.
Holistic
• 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.
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).
• 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. JAMA278(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