Few would argue against the important of compassion in healthcare professionals who care for people facing the end of life. But what this means in reality is not well-articulated. Is it even possible to identify or measure compassion in clinical practice? And, even if it could be measured, could interventions be designed which would enhance or increase it? And why is it that individuals vary so much in their natural compassion; I am reminded of two extreme examples I have seen this year. In the first, a harassed nurse in an overloaded A&E unit in a hospital in the South was overheard arguing with a policeman – I was far away, but I was able to pick up the essence of the content. A man had been injured during a gunfight, and brought in for medical treatment. He was in handcuffs. The nurse was arguing that given the extent of blood loss he was fighting for his life and was extremely agitated and distressed. She was asking the policeman to uncuff the patient. Her argument was that he was far to weak to attempt an escape, that it was a basic human right, and the policeman needed to see beyond his role to “do the right thing”. Despite the intimidating appearance of the patient, the unspoken obligations to work alongside other professionals and present a united front, and the busy and hectic ward, this nurse had somehow shone a light directly on to the common humanity that existed between her and this suffering man.
The other example took place when I visited an elderly relative, let us call her Vera, recently in an acute medical ward in a hospital in the North. She had been admitted with dysphagia of unknown cause, and described a “choking” feeling every time she tried to swallow food, even liquids. A basic speech & language assessment had failed to elicit an organic pathology for this, and the conclusion of the healthcare team was that the symptoms might have a psychosomatic component. In the meantime, she had been admitted acutely with worsening heart failure. Vera’s legs were oedematous and she could not breath when lying flat. The ward were closely monitoring her pulse rate in order to maintain her digoxin levels at therapeutic dose, and her weight, in order to monitor the efficacy of her diuresis. Her eating problem was barely mentioned in the notes. Her weight had reduced from 53kg to 42 kg in the space of a fortnight. She was drowsy and lethargic when seen, her cheeks sunken. Still smiling, her response when we asked her how she was? “I can’t complain”. Her eyes told a different story. When I asked if she was frightened, Vera nodded, and her eyes widened. “I just want to be at home if they can’t make me any better”. When asked about the care plan, and her oral intake, the staff nurse referred to the notes. “Oh, I see she has an ENT appointment in 6 weeks”, closing the notes decisively, as if to say “that’s that”. Well, I’m no mathematician, but a weight loss of approximately 20% in 2 weeks, albeit confounded somewhat by the fluctuations in her fluid levels, would leave her just about invisible, likely dead, by the time said appointment arrived. When asked about the plan, the nurse responded that they would closely monitor her weight and keep giving her medications. When asked directly about whether the focus was now on palliation, the staff nurse’s eyes looked just about everywhere but in mine, her awkwardness was palpable, she fumbled for an answer which contained certainty, but there was none.
This nurse had not done anything wrong; no professional regulations had been transgressed, no law had been broken. But this patient had been lying in a hospital bed, silently shrinking and dying, uncomplaining. A model patient, really. This was not a case of a cruel nurse willingly neglecting an elderly patient. In reality, Vera’s suffering, worries and confusion had not been recognised at all. Nor had the plethora of reasons behind her apparent psychosomatic self-starvation.
I began to think about compassion, and to read about the theory. Unsurprisingly, there are many (I’ll write this up in another blog…). Essentially, however, all the theories seem to agree that in order for compassion to be present, the following two ingredients must be present:
- recognition that another human is suffering (whether that suffering is physical, emotional or spiritual)
- response or reaction to that perceived suffering (intention/ motivation)
One cannot be said to be compassionate if one has not recognised that suffering is there in the first place. The staff nurse caring for Vera was not a cruel person. She was focused on her role within a biomedical paradigm, and within that role, all was well. I reflected that there must be many reasons for her apparent failure to recognise suffering, such as experience, how busy she was on that day, demands of other patients, confidence, attention. I reflected on two of the key recommendations of the Francis Report, that prospective nursing students spend a year working as a healthcare assistant prior to beginning pre-registration training, and that compassion is embedded in the curriculum. I also revisited the pages of the Neuberger Inquiry into the alleged failings of the Liverpool Care Pathway. I realised these two key contemporary reports are both grappling with the same fundamental problem. What is the nature of compassion? What gets in the way of its expression? How can we make things better for people who find themselves dying within the walls of a hospital in the 21st century.
This is what gave birth to the idea for this project. My plan is to keep a blog as I undertake my work, partly to help me clarify my thoughts, partly to make this open to feedback, collaboration and discussion. I welcome your comments.