Phase I Home Page
The Language of
Bioethics (Glossary)
Objectives
Goals
Required
Reading
The
Patient's Emotional Reaction to Illness
The
Physician's Responsibility
Clinical
Vignettes
Discussion
Questions
Suggested
Reading
References
& Resources
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The Patient as Person
Responses to Illness, Living, Dying and
Bereavement
Objectives
To explore the personal and psychosocial effects
of illness in the life of a patient, productive and nonproductive means of
coping with those effects, and the role of the physician in this process.
To explore the impact of dying and death upon the
students/physicians, patients and their families, and the difficult decisions
concerning the treatment of the dying patient.
Goals
- Recognize the patient's emotional reaction,
his illness, his family and his physician.
- Understand physician's responsibility toward
his ill patient.
- Recognize the influences of age, culture,
ethnicity, education on patient response to and manner of coping with
illness.
- Recognize the impact of death and dying on the
physician and patient/family.
Required Reading
- Introduction to Clinical Ethics by
Fletcher, Miller, Lombardo and Marshall. Second Edition.
"Treatment Refusals by Patients and Clinicians," p 109-125
- Excerpts provided with this outline, from Paul
Ramsey's The Patient as Person and William May's The Patient's
Ordeal.
The Patient's Emotional
Reaction to Illness
The
Physician's Responsibility
- Determine the cause of the illness
- Treat the symptoms
- Understand and support the human being who is
experiencing those symptoms
Clinical
Vignettes
The following reading is taken
from the Preface to
Ramsey's The Patient as Person (1970).
These are by no means technical problems on
which only the expert (in this case the physician) can have an opinion. They
are rather the problems of human beings in situations in which medical care is
needed. Birth and death, illness and injury are not simply events the doctor
attends. They are common moments in every human life. The doctor makes
decisions as an expert but also as a man...and his patient is a human being
coming to his birth or to his death, or being rescued from illness or injury
or in between.
Therefore, the doctor who attends the case has
reason to be attentive to the patient as person. Resonating throughout his
professional actions, and crucial in some of them, will be a view of man, an
understanding of the meaning of the life at whose first and second exodus he
is present, a care for the life he attends in its afflictions. In this respect
the doctor is quite like the rest of us, who must yet depend wholly on him to
diagnose the options, perhaps the narrow range of options, and to conduct us
through the one that is taken.
The next reading is from the
Introduction to May's
The Patient's Ordeal (1991).
Pregnancy and birth pose for the young mother
and father a series of signs marking discrete tasks to perform and apparent
crisis to learn how to take in their stride...But birthing and parenting, at
their deepest levels, profoundly assault and alter human identity; they limit
and redefine the parents' freedom and their future; the advent of the child
suddenly converts the couple's pad into a nest and reminds the parents of
their own impinging mortality.
Health crisis...confront their victims with
things to do; but far more profoundly, as such crisis assault identity, they
force their victims to decide who and how they will be. The successful
businessman who ponders how to save his limited and valuable time puts a
telephone in his Mercedes. It lets him pursue his business and care for its
details even while stalled in a traffic jam. But suddenly a blood clot stalls
in his coronary artery; the rescue unit pulls him out of his care and wheels
him into an intensive care unit. Suddenly he finds his time even more limited
than he thought. The catastrophe confronts him with problems to solve; but
these problems pale before the deeper question: who and what is he now that he
has suffered this explosion from within? Accustomed to commanding his world,
the patient suddenly finds himself helpless in the hands of nurses down the
hospital corridor; used to total obedience from his subordinates, he discovers
that the very humblest of his subordinates, his own body, has rebelled against
him.
The language of the surgery team reflects the
profound changes the patient undergoes. Staff members regularly identify
surgery patients as pre-op day one, post-op day two, or post-op day four.
These designations serve the staff functionally and prosaically to flag the
services scheduled for a particular day and to mark the standards for the
patient's progress and recovery. Symbolically, however, the marking of the
calendar can also signify a great deal more for the patient. It reflects the
patient's sense of a changed and often reconceived and reordered life. Surgery
and serious illness traumatize the calendar. The woman refers to "before
my surgery last October" or "before my stroke last summer." The
man thinks, "before my heart attack last February." The crisis
divides and reorders time. It can loom, in the personal scheme of things, as
large as 4 B.C. and A.D. 30 or A.D. 1990. The crisis serves as sacred event in
the sense that it galvanizes time around it-before and after.
The doctor, the plumber, and the expert may
puzzle to solve problems. Once they solve a problem, they move on to other,
perhaps different, certainly new quandaries. As they handle cases, they
enhance their expertise and sharpen their skills, but, traditionally
conceived, they themselves do not usually change. In a sense, qua expert, they
have little history; self-transformation is not usually a issue.
The person, however, who experiences a
catastrophe moves from life through a kind of death into some sort of new
identity. She participates in making history. She partly shapes her own
narrative in response to fateful events. In the course of that shaping, she
will need to solve problems. But those problems do not pose the real issue.
She herself is the problem.
When the medical staff has finished its work
and snatched the patient from the jaws of biological death, the agony has just
begun to some of the patients...
Discussion
Questions
- If the physician, as "expert" in
Ramsey's writing, is one of many who holds an opinion about the person who's
case he attends, what other opinions are relevant?
- How do the physician's opinion interact with
the patient's, especially in view of May's accounting of patient
perspectives and ordeals?
- What is considered by you to be a
"normal" response to illness? If you have experienced significant
illness, been hospitalized or had surgery, what affected your own response
to your diagnosis? Your condition?
- What is the physician's responsibility in
knowing and responding to the patient's perceptions and reactions to
illness?
- Relate how any experience with the death of
someone you've known has been revealing of the impact that death and dying
can have on you, or on others who've known the deceased.
- What is the likely impact that having no
experience with death and dying prior to medical school will make on a
medical student? Intern?
Suggested Reading
Note: Articles 1-3 can be found through Ovid and will require an ID
and password.
- Cassel
E J. The Nature of Suffering and the Goals of Medicine. N Engl J Med
1982; 306:639-45.
- Wanzer,
SH, et al. The physician's responsibility toward hopelessly ill
patients. N Engl J Med 1984; 310: 955-9.
- Wanzer,
SH, et al. The physician's responsibility toward hopelessly ill
patients: A second look. N Engl J Med 1989; 320:844-9.
- The Doctor's Dilemma by Martin, Reese, Browne and Baros-Johnson
"Miller Case"
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