Compassion in Healthcare (CARE1)

• CARE1 addresses compassion in healthcare
• Presented by Dr. Sally Doherty and Prof. Denis Harkin

Learning Objectives

• Define compassion in healthcare
• Describe compassion, including empathy, cultural sensitivity, and patient-centered care
• Identify compassion deficits in a clinical scenario
• Discuss the impact of these deficits
• Apply professional principles to compassion in a clinical scenario

CARE Reflection

• Reflection is a cognitive process used to:
  • Gain insights
  • Rethink practice
  • Learn from experiences
  • Cope with similar situations in the future

Selection

• Attributes of good doctors include character qualities
• Character qualities are compassion, altruism, respect, and integrity
• Character Qualities are emphasized in the admission criteria and selection of physicians
• Measures of moral reasoning include:
  • The Moral Judgement Interview (MJI)
  • The Defining Issues Test (DIT)
  • The Sociomoral Reflection Measure (SRM)

CARE Quote

• True compassion = feeling another's pain + being moved to help relieve it

Compassion Definition

• Compassion is the feeling that arises when a person is moved by the suffering of another + a desire to relieve it
• Having compassion requires:
  • Fellow-feeling
  • Sympathy
  • Pity

Empathy versus Sympathy

• Empathy:
  • Ability to understand and share the feelings of another
  • Is is always beneficial to patient-physician relationships
  • Leads to personal growth and career satisfaction
• Sympathy:
  • Feelings of pity and sorrow for someone else's misfortune
  • Can be detrimental to patient-physician relationships if in excess

Professionalism

• Professionalism is a set of values, behaviors, and relationships with underpins the public trust in doctors
• Compassion is a core element of professionalism
• Related characteristics are altruism, integrity, partnership, excellence, continuous improvement

Unprofessionalism

• Not pertaining to the characteristics of a profession
• Behavior/ conduct that adversely affects ideal team functioning
• Includes bullying, sexual harassment, rudeness, passiveness/aggressiveness, and demands

Ethics

• Ethics is the normative science of conduct for human beings living in societies
• Ethics judges conduct to be right/wrong or good/bad.
• Related concepts include autonomy, justice, beneficence, and non-maleficence

Beneficence

• Actions or rules aimed at benefiting others
• Acts of mercy, kindness, generosity, and charity
• David Hume's “moral-sentiment" theory: benevolence is central
• John Stuart Mill's utilitarian principle: actions are right if they lead to beneficial consequences
• Kant argues that everyone is duty-bound to be beneficent

Non-maleficence

• Ethical principle of doing no harm, based on the Hippocratic maxim
• "Primum non nocere" meaning, first, do no harm
• Gert's theory of moral obligation:
  • Nonmaleficence is central
  • Beneficence is not essential

Compassion in Healthcare (Professionalism)

• The Canadian and American Medical Associations list compassion as a core virtue to be exemplified by ethical physicians
• The Canadian Medical Association (CMA) states:
  • A physician recognizes suffering and vulnerability
  • Understands unique circumstances
  • Alleviates suffering
  • Accompanies the suffering patient

Compassion in Healthcare (Theory)

• Compassion is associated with positive effects on the patient experience
• Improves patient-reported outcomes
• Outcomes are:
  • Reduced patient symptom burden
  • Improved quality-of-life
  • Enhanced quality-of-care ratings

Compassion in Healthcare (Theory cont.)

• Signifying compassion from the patient’s perspective includes:
  • Kindness, authenticity, attentiveness
  • Relational connection
  • Displaying presence+ warmth
  • Acceptance, understanding, listening
  • Helping, communicating effectively
  • Being involved and gentle and caring

Healthcare Professionals (HCPs)

• When there is limited time the professional exhibits characteristics like:
  • Thoughtfully connecting with patients
  • Acknowledging difficulties
  • Using humor
  • Comforting physical gestures
  • Relating to patients

Compassion (Patients and Carers)

• Palliative Care Patients and Providers view compassion through:
  • The Patients Perspective- a virtuous response that seeks to address the suffering and needs of a person through relational understanding and action
  • The Healthcare Providers (HCPs) Perspective- a virtuous and intentional response to know a person, discern their needs and ameliorate their suffering through relational understanding and action

Compassionate Care (NHS- National Health Service)

• Care is the core business.
• Compassion is the how care is delivered through relationships that value empathy, respect & dignity.
• Communication is central to successful caring relationships and team work.
• Courage allows to speak up when there are concerns for care.
• Competence- Those who provide care have the ability to understand needs.
• Commitment to patients and populations.

Compassion (Extreme Medical Conditions)

• Loren Schauers, age 20, underwent hemicorperectomy back in 2019
• Body pinned under a four-ton vehicle in Wilsall, Montana
• Rare and risky surgery includes removal of patient legs, genitalia, urinary system, pelvic bones, anus, and rectum
• Medics removed Schauers' right arm
• Schauers has since married his childhood sweetheart

Empathy

• Ability to understand and share the experiences of another + see things from their perspective + imagine yourself in their place

Teaching Empathy through Communication Skills Training

• Kataoka's study finds that students' empathy increased significantly following communications skills training program
• Areas of improvement- Perspective Taking + Compassionate Care
• However, targeted reinforcements may be needed to sustain improvements

Empathy in Medical Students

• The Jefferson Scale of Empathy (JSE)
• Significant decline in empathy scores in the third year of med school(Clinical)
• Erosion occurs during the clinical years
• Erosion also occurs when empathy is most essential

Jefferson Scale of Empathy (JSE)

• Measures empathy in HCPs and students
• Developed by Dr. Mohammadreza Hojat
• Used in 88 countries
• Empathy in patient care = Ability to understand/communicate patient's pain, suffering, or perspective + an intention to help
• Items scored: Strongly Disagree (1) to Strongly Agree (7)

Altruism

• Disinterested and selfless concern for the well-being of others
• Derives from French word "autrui," meaning "other people"
• Egoism ethical theory treats self-interest as the foundation of morality
• Derives from the Latin term "ego"
• Psychological Altruism: motivational state/goal of increasing another's welfare

Evolution of Altruism and Cooperation

• Darwinian, evolutionary theory On The Origin of Species: survival of the fittest
• Evolution is a slow process, so Hamilton & Modern Theory on Cooperation and Altruism addresses why we help
• Reasons include:
  • Direct benefits to the individual
  • Repeated Beneficial Interactions with Unrelated-Individuals
  • Preferential Interactions between Related-Individuals
  • Genetic predisposition to Altruism (Helping Phenotype)*
• Cost-to-benefit ratio can be altered by coercion, punishment and policing
• Results in behavioral patterns which add to the gene-pool

Altruism, Volunteering and Wellbeing

• Examines the US based analysis of Volunteering and depression via psychological and sociological aspects
• Key findings
  • Volunteer work improves access to social and psychological resources + counters negative moods
  • Prolonged exposure to volunteering benefits both young and old

Altruism and Organ-Donation (Live-Donors)

• Jordan in-depth review of Kidney & Liver Live-Donors that involved:
  • Pre-donation was characterized by fear and confusion
  • Post donation reflected a positive emotional state with self-satisfaction + pride + increased support of organ donation.
  • Social solidarity + the donors beliefs largely motivated the desire to improve the recipient's life

Heroism

• Great bravery (courage, valour) and selflessness
• Often a product of extreme situations, classically war and violence
• The Hero acts, whilst the Bystander watches
• People who risk their lives in the service of another tend to
  • Take great risks, have compassion, kindness & empathy + be altruistic

Self-Care and Wellbeing (Doctors in Ireland)

• Doctors in emergency medicine and physicians were most likely to meet the criterion for burnout.
• 50% of doctors in Ireland are emotionally exhausted and overwhelmed by work.

Freudenberger's "Staff Burnout"

• Published in 1974
• "Burnout” defined as the synonym for psychosomatic, psychological, and social consequences of workload chronically exceeding an individual's capacity to cope

Maslach Burnout Inventory

• Test commonly used to assess Work Burnout
• Measures emotional exhaustion, depersonalisation, personal accomplishments, cynicism, and professional efficiency
• The World Health Organization considers Burnout an "Occupational Phenomenon”

Patient-Centred Care

• The Institute of Medicine defines patient-centred care as providing:
  • Respectful and responsive care
  • Individual patient preferences
  • Needs and values -Ensuring patient values guide all clinical decisions.
• Institute standards in the medical field include: -Professionalism; caring for patients -Physical, psychological & social aspects -Excellent care and good communication between all medical stakeholders

Personalised Care and Support (UK)

• The Coalition for Collaborative Care has outlined 10 principles of Patient Centred Care (PCC): -Person-First, Safety, Personal Responsibility,Defined Authority
  • Clear Accountability, Leadership, Interdisciplinary Working, Supporting Performance, Open Culture, and Continuous Improvement

Communication in Patient Centred Care

• Six components in patient communication circle:
  • Fostering healing relationships
  • Responding to patient emotions
  • Exchanging information about needs
  • Enabling patient self-management
  • Engaging in informed and collaborative decision-making

Florence Nightingale

• British nurse and social reformer (1820-1910)
• Known as the "founder of modern nursing"
• Wealthy background, classical education, studies in Germany and at Middlesex Hospital
• Crimean War Nursing Corp sanitation focused (Prevention Cholera)
• "The Lady With the Lamp" compassion for the sick
• Altruism results in "Crimean Fever"
• She Established St. Thomas' Hospital and Nightingale training school for nurses in 1860

Staffordshire Hospital Scandal

• Mid Staffordshire Hospital Scandal involved poor care + high mortality rates
• Julie Bailey whose mother died in hospital led campaign in 2007 called Cure the NHS to demand changes
• 400-1200 excess deaths occurred (2005-2008)
• Healthcare Commission reported cutbacks to staffing in order to gain financial surplus
• The Francis Report released in 2010

Public Inquiry Key Facts

• The Francis report inquiry had:
  • Over 1 million of documentation
  • Over 250 witnesses throughout 139 days

A Lack of Care and Compassion

• A nursing home patient displayed a lack of proper/ professional care.

Report of the Mid-Staffordshire NHS Foundation Trust

• "People must always come before numbers."

American Board Internal Medicine Foundation focuses on:

• The Primacy of Patient Welfare (altruism, trust & patient interest)
• Patient Autonomy (honesty & empowering the patients)
• Social Justice (physicians' consider available resources & the needs of patients)

Medical Council of Ireland (IMC)

• Recognizes that patients are diverse
• Recognizes patients have the right to be treated w/ dignity and respect
• Care of patients takes the center stake
• Act promptly to ensure the safety, dignity and comfort of patients & colleagues

Recommendations and Standards

• Should include openness, transparency & candor
• Compassionate, caring & committed nursing
• Strong patient-centered leaders
• Establish & use accurate, relevant data
• Culture change that is not dependent on government

CARE scenarios to contemplate

• 71 year old male w/severe COPD admitted to the ICU with Pneumonia, Sepsis
• Family discussion needed with patient w/his advanced decline in the hospital