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CURRENT CONTROVERSIES IN CRITICAL CARE |
Effective communication is one of the social conditions of possibility required in order for anyone to develop a capacity for agency and autonomy, and for that agency to be effectively expressed in public settings. Effective, compassionate communication creates social, moral, and sentient public spaces where patients and families can be heard, recognized, and thus increase their understanding of their possibilities and/or be comforted. Such a social space requires attunement, compassion, and effective 2-way communication on the part of healthcare workers. Compassionate understanding at such times of crisis is a good in itself, regardless of what strategic aims might be accomplished in this social-relational space that fosters recognition and disclosure, rather than silence, neglect, or abandonment.
Recent articles have begun to report qualitative research findings on the role of the nurses assigned to communicate with patients and families and physicians about prognosis and end-of-life care in the SUPPORT study of end-of-life care in acute care settings.1–3 The nurses’ interventions made no difference in phase 2 of the SUPPORT study interventions designed to (1) deliver patient-specific prognostic reports for survival and function of the patient and (2) facilitate communication among patients, families, and healthcare providers. None of the following 5 strategic quantitative outcomes was altered by the communication interventions carried out by nurses: (1) incidence and timing of do not resuscitate orders, (2) patient-physician agreement on cardiopulmonary resuscitation preferences, (3) days in intensive care unit in a comatose condition or receiving mechanical ventilation, (4) pain incidence; and (5) hospital resource use. These strategic quantitative outcomes failed to capture the benefits of nurses working with patients’ and families’ readiness to transition from primarily curative to primarily palliative care. Lynn4 concluded that the SUPPORT study placed too much emphasis on rational decision-making process and too little on the human aspects of facing suffering and death.
In reviewing the nurses’ narrative reports of their interactions with patients and families, the nurses’ repeatedly described effectively communicating so that patients and families (1) understood the patient’s clinical situation and (2) felt heard and understood. They concluded that effective communication was essential to perceiving and facilitating patient and family "readiness" for healthcare decision making. Readiness is illustrated in the following 3 excerpts from nurses’ narratives:
She stated that she did not want to go back on the ventilator. She told me she knew she was dying and that she was afraid that she wasn’t ready.He thanked me and said that he needed to know that. He began to cry and said no one would tell him. I knew he had been told in our meeting months ago, but I also knew that both he and his wife were not ready to listen then.
. . . it is almost as if she had taken care of her son for 30 some years and she would stay alive on the ventilator a few more days if that helped him come to terms with her death.2
Emotional availability and connection open up a social, sentient space where others can be met and their concerns, capacities, and vulnerabilities can be expressed. Readiness, as described earlier, is created and facilitated in such moral sentient spaces.
In her groundbreaking new book on the role of compassion in leading a good life and developing a good society, Martha Nussbaum5 notes that compassion is needed at 2 levels: (1) the level of individual psychology and (2) the level of institutional design. Compassionate individuals and institutions mutually reinforce one another:
. . . Institutions teach citizens definite conceptions of basic goods, responsibility, and appropriate concern, which will inform any compassion that they learn. Finally, institutions can either promote or discourage, and can shape in various ways, the emotions that impede appropriate compassion: shame, envy, and disgust . . . . Compassion requires the judgment that there are serious bad things that happen to others through no fault of their own . . . .5
Nussbaum notes that in the Western tradition, we have 2 main views of the role of compassion in our moral encounters with others:
One vision is based upon the emotions; the other urges their removal. One sees human being as both aspiring and vulnerable, both worthy and insecure; the other focuses on dignity alone, seeing in reason a boundless indestructible worth.5(pp367–368)
The first, the Stoic and Kantian traditions that focus on will and autonomy of the individual fail to notice the social conditions and human relationships required to make the individual’s will and agency possible and socially recognized. In fact, a false stoic assumption is made that acknowledging tragedy or victimhood negates the person’s strength and agency. However, as Nussbaum points out: "Agency and victim-hood are not incompatible: indeed, only the capacity for agency makes victimhood tragic."5
Nussbaum critiques the Stoic and Kantian moral traditions that focus on the removal of moral emotions attending only to the will of self-controlled, autonomous individuals. Human beings are both dignified and needy, as well as being independent and dependent. A compassionate institution will create social and sentient spaces that facilitate healthcare providers in meeting vulnerable or suffering individuals. Compassion requires that the dignity and agency of human beings be respected.
Two emotional errors must be combatted in compassionate care: sentimentalism and moralism. According to Logstrup,6 both sentimentalism and moralism occur when the sentiment or moral emotion becomes the end or focus instead of the concern or goal that elicited the emotion. In the case of sentimentalism, one focuses on the emotional plight of another and elaborates that emotion by turning it inward and imagining or acting as if the plight of the other is one’s own, despite the fact that one’s own world remains unchanged or that one focuses on the experience of the feeling rather than addressing his/her attention to the concerns generating the feeling. In sentimentalism, one sensationalizes the other’s emotional experience. Moralism takes a similar kind of inward focus in that moralism (not morality, ie, actualizing the good life, ensuring justice and respect) attends to the character trait as an end in itself, rather than the ends or goals that need to be addressed by the character trait, such as compassion or meticulousness:
. . . Certainly, character traits can be trained, but not for their own sake and not without the help of desire . . . . While we struggle with a problem, the character trait that conditions the solution of it is developed. Strengthening of character is the result of the pleasure that appears from a fortunate outcome and even in the process of the struggle itself with the problem. But it is a fatal displacement if one turns one’s back on the task in order to concentrate on the character trait in order to derive any pleasure from it. Very soon, it is destroyed and in more than one way. The character trait stiffens, becomes its own caricature and breeds self-satisfaction.6. . . Mercy consists of an urge to free another human being from his sufferings. If it serves another goal, for example, the stabilization of society [or the development of character], it is replaced by an indifference towards the other person’s sufferings. The ulterior motive transforms mercy into its opposite.6
Medicine and nursing draw on the tradition of the role of the compassionate stranger, one who responds to the tragedy of others out of compassion and solidarity with the tragedies inherent in the human condition. Compassionate strangers are needed because family and friends are not always available and often are overwhelmed with the tragedy that has befallen their loved one. The compassionate stranger can be effective in meeting and helping the vulnerable person by not engaging in sentimentalism or moralism, and directing his or her compassion to the immediate concerns at hand. Compassion, like other notions of a good life, is both social and individual. Compassion requires institutional structures that support and reinforce social, sentient moral spaces for meeting one another. These moral spaces cannot exist for the sake of efficiency or character development, but must be appreciated and structured as ends in themselves. Nussbaum,5,7 drawing on the work of Sen,8 concludes that every society ought to ensure a threshold level of at least 10 capabilities: life; bodily health; bodily integrity; senses, imagination, and thought; emotions; practical reason; affiliation; living in respectful relation with nature and other species; play; and control over one’s political and material environment. Her definitions of emotional and affiliative capacities give a moral vision for what is required in developing compassionate individuals and institutions:
Emotions: Being able to have attachments to things and people outside ourselves; to love those who love and care for us, to grieve at their absence; in general, to love, to grieve, and to experience longing, gratitude, and justified anger. Not having one’s emotional development blighted by fear and anxiety. (Supporting this capability means supporting forms of human association that can be shown to be crucial in their development.)
Affiliation: Being able to live with and toward others, to recognize and show concern for other human beings, to engage in various forms of social interaction; to be able to imagine the situation of another. (Protecting this capability means protecting institutions that constitute and nourish such forms of affiliation, and also protecting the freedom of assembly and political speech).5 (p 417)
In describing these capabilities, Nussbaum has in mind the society as a whole. How much more important is it to uphold these individual and institutional capabilities in the intensive care unit, where the mission is to help compassionate strangers meet and respond effectively to human suffering? These outcomes—meeting and responding effectively and compassionately to suffering—were omitted from the outcomes originally measured by the SUPPORT study.
To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.
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