What is compassion? And how does it relate to suffering?

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.

 

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One thought on “What is compassion? And how does it relate to suffering?

  1. I think this is a compelling subject. I haven’t thought before of compassion as consisting of both recognition of suffering and a response to it, but it makes sense and feels very helpful in considering what happens in healthcare settings.

    As a doctor working in palliative care I feel privileged to work with many caring, courageous, committed individuals who I greatly respect. At times, though, I come across situations in which caring staff appear not to practice compassion. Here are four scenarios which are familiar to me:

    1. Acute hospital. As in the case of Vera, a narrow focus often prevents the recognition of a bigger picture –of either physical or psychosocial problems and of the suffering which accompanies them. The narrow focus can be biomedical; specialty specific; location specific (ie lack of awareness or interest in what will happen after discharge from hospital); – or often a combination of several! Even if suffering is recognized, there may be a poor response due to a perceived lack of skills, time or appropriate colleagues to refer on to. Or due to a rigid imposition of organisational policy (as in the case of the man under arrest). I think these observations hold true across a wide variety of professions.

    2. Community. Sometimes, nursing staff appear to recognize the suffering but do not see it as their job to respond to it. They try to pass the task to someone else, or simply refuse to do it. This seems to be getting commoner and it shocks me. I don’t know if it is due to concern about the boundaries of their roles, directives from management or just a sense of being overwhelmed by the workload they are presented with.

    3. Hospice inpatient unit. Most staff are highly conscientious, even perfectionist about the standard of care they give. They both recognize and respond readily to the suffering in front of them, (though their response often focuses more on the physical than the emotional/spiritual). However, whilst providing excellent direct care, some staff struggle to recognize and respond to the needs of other patients waiting for admission: they may lack a sense of urgency about planning the discharge of existing patients and arranging the admission of those waiting and suffering in another setting.

    4. Another observation from hospice inpatient units: I am surprised to see nursing staff sometimes let their natural likes and dislikes for individual patients lead to bias in their management decisions, for example as to whether an individual should be discharged or remain in the hospice. In my experience, this seems to be less of an issue amongst medical staff – I’m not sure why – maybe they have a stronger inculturation of the principle of treating patients impartially according to need, regardless of personal feelings about the patient’s personality, level of responsibility for their illness (eg caused by smoking or obesity); or about matters of race, gender, religion, sexuality etc.

    There are clearly multiple factors at work in all the cases discussed. This tends to make me feel overwhelmed when thinking about how to encourage more compassionate care. However, it occurs to me that they all share two attributes – firstly, a lack of sufficient listening to really appreciate the reality of someone’s suffering – and secondly, a failure to step back and ‘see a bigger picture’ of both the nature of the suffering and of what could and should be done in response. I wonder whether these two factors underpin much of the lack of compassion we encounter, and whether finding ways to reflect on them with staff or students might be a simple and fruitful way of starting to consider what exactly compassionate care means?

    I’m interested that these principles of careful listening and of learning to see things clearly and completely are both considered central to the practice of mindfulness meditation (or ’awareness training’ – I heard someone recently suggest this might be a more immediately understandable term than mindfulness). The principles are inspiringly described from this perspective here: http://www.explorefaith.org/tnh/tnh_pm.html

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