THE NIB FORUM is a place to share current calls for stories and to discuss intriguing stories, narrative symposia, and articles. Occasionally, we publish commentaries from guest writers. The Forum also publishes stories that complement narrative symposia.

Comments are welcome. Approved comments will ordinarily be posted within 1 business day.

Tuesday, June 26, 2012

On Touch

Narrative Inquiry in Bioethics is very proud to introduce our first posting by Jocelyn Streid. She is going to post regularly for us for the next year. Jocelyn is a Robertson Scholar and pre-med student at Duke University and is interested in medical humanities. Welcome aboard Jocelyn!

On Touch

By Jocelyn Streid 

“You must learn to touch the patient. So many doctors – they do not want to touch. We cannot take care of the patient unless we touch." 

When I was twenty years old, I shadowed a physician in rural South Africa. This was the advice she gave me as we stood before a patient suffering from HIV/AIDS. He had literally wandered in off the street, and now he sat before us – delirious, covered in a Kaposi’s sarcoma rash, and rendered silent by acute oral thrush. Still new to the smells of advanced HIV/AIDS, I could barely breathe. I imagined the wide berth people must have given him on his way here – to touch him was my last instinct.

As I read the narratives of CNAs in the Winter 2011 edition of Narrative Inquiry in Bioethics , I couldn’t help but think of the South African doctor’s words: “You must learn to touch the patient.” These contributors tell stories of touch – of bathing, of cleaning, of repositioning, of toileting, of feeding. It is physically intimate labor of unmediated contact, perfectly captured in Tracy Dudzinski’s term for herself: a “direct-care worker.”  Yet as physically exhausting it may be, the practice of touch can be one of the most rewarding elements of a CNA’s career. It is with pride that James Bradley writes, “I am a carer. A hands-on, at-the-bedside, hand-holding, bed-bathing, carer.”

The meaning of touch in healthcare settings has garnered more and more attention in the past several years, in part due to writer and physician Abraham Verghese’s discussion on the topic. In his essay “A Touch of Sense,” he observes that many doctors view the physical examination as “hardly worthwhile,” since the ever-increasing prevalence of technological diagnostic tools can render actual doctor-patient contact seemingly unnecessary.

Consequently, modern medical practice tends to isolate physical touch to less-glorified members of the healthcare team, forgetting its significance and exemplifying a larger societal shift away from manual work. Physical labor, after all, receives little cultural or financial recognition – blue-collar workers work with their hands; white-collar workers do not. The language used to describe this type of labor reflects the hierarchy. CNAs, it is sometimes said, do the “dirty work.” The implied dichotomies of clean/unclean and pure/impure suggest that the direct care offered by CNAs is inferior to the indirect care offered by other members of the healthcare team. Their work is perceived to be the performance of basic physical tasks with little recognition of the importance of those tasks. As Nanci Robinson explains, “When someone says they are a CNA…Images of caring, compassionate and educated people should come to mind, not someone holding a bed pan.”

Though CNAs work to retain the practice of touch in modern healthcare, much has been lost in its decreasing prevalence. When commentator Delease Wear describes her father’s time in the hospital, she recalls the CNA’s name and thinks of “the smell of the lotion she rubbed on his body.” Other professionals, however, are noticeably absent from her memory – “We never spoke directly to the medical director of the hospice. He was a phantom, rounding at 5 or 6 a.m.; we came to believe he did so to avoid speaking to families.”

Touch, then, is both a symbol of and a vehicle for good care. It is easy to see why patients might feel more alienated from their providers as touch becomes replaced by computer screens and diagnostic imaging. Verghese bemoans the loss of touch as a physician-patient ritual. He writes,

“With the explosion of knowledge, the whole human genome mapped out at our feet, we are lulled into forgetting that the ritual is cathartic to the physician and necessary for the patient, forgetting that the ritual has meaning and a singular message to convey to the patient. And the message, which I didn’t fully understand then, even as I delivered it, and which I understand better now, is this: I will always, always be there, I will see you through this, I will never abandon you, I will be with you through the end.”

CNAs fill a vital role many physicians have long-abandoned. They are those who comfort, those who provide, those who touch. I think of Tracy Dudzinski’s story of an elderly man for whom she cared. Their relationship, I am sure, was one of touch, and when he passed away, his son asked her to be a pallbearer for him. The importance of her touch extended past death; he had asked her to use her hands and touch his casket, even after he could no longer feel the contact. I can’t help but wonder what medicine might look like if more providers remembered that to touch is a privilege, and to be touched can be a gift.

Sunday, June 17, 2012

“Reasonable Accommodation” for Families of ‘Brain Dead’ Patients

The NIB Forum is pleased to post a contribution from a board member, who comments on a case study from volume 1, issue 1.

“Reasonable Accommodation” for Families of ‘Brain Dead’ Patients

By Jeffrey Spike, PhD

Martin L. Smith and Ann Lederman Flamm published a Case Study in Narrative Inquiry in Bioethics’ first issue (Vol 1, No 1, Spring 2011, pp. 55-64): “Accommodating Religious Beliefs in the ICU: A Narrative Account of a Disputed Death.” It was a careful and detailed description of a woman, Sarah, in her mid-to-late 20s who is left dead by neurological criteria after an apparent un-witnessed cardiac arrhythmia at home. There have been a number of discussions of cases like this, including one I wrote with a colleague over 15 years ago (Jeffrey Spike and Jane Greenlaw, Journal of Clinical Ethics, Vol. 23, No. 3, Fall 1995): “Persistent Brain Death and Religion: Must a Person Believe in Death in order to Die?" The title was deliberately provocative, both in inventing a new term for these corpses that exist in limbo, dead but pink and breathing thanks to a ventilator and drugs to maintain blood pressure, and also deliberate in raising the question of the intersection between personal beliefs (including religious beliefs) and medical realities.

The outcome of the case in Smith and Flamm was described as a deus ex machina: another hospital accepted the transfer of the patient. Thus their article leaves it an open question for others to consider: what should be done in such cases?

Here then are some suggestions. First, it is important to acknowledge, as has been well argued in the philosophical literature for years (indeed, millennia), that a person can be harmed even after they die. Harms (and benefits) include, but are not limited to such subjective experiences as pleasure and pain, or happiness and suffering. Very few people wish to be 'kept alive' (physiologically) in this condition. A few religions have resisted accepting the newer scientific definition of death, and so have (for some commentators) transformed this into a religious freedom issue.

These are difficult and controversial issues. So it is no surprise that few commentators have confronted them. But that is what Smith and Flamm suggest is needed, and so it seems appropriate to bring attention to some proposals already in the literature. Because much of the ethics literature is not documented in PubMed or MedLine searches, there is a danger of progress being set back by each person having to re-invent the wheel. So this Forum piece is meant to let people with an interest in this issue avoid having to spin their wheels: at least you can begin where others left off.

First, Spike and Greenlaw concluded that continuing life-support for the deceased merely to placate the family, that is, without any evidence of the patient's wishes, is insufficient justification. (p. 292). The reason is, in part, that studies have shown that a vast majority of people would not want this intervention, and see the resulting survival (if it can even be called that) as an affront to their dignity. To use my own terms: most of us prefer to be remembered by loved ones for our happy times together, not as an unconscious and dependent corpse in diapers who is visited in a hospital or Long Term Care ‘rehabilitation facility.’

We also addressed the mistaken belief that no harm is done by adhering to the family's wishes. The best philosophical reflection on this issue from Aristotle to Rachels, Veatch, Feinberg, Nagel, and Pitcher all agree that a person can be harmed even after they die. Granted, this is a subtle issue, requiring careful reflection. But few people, after careful reflection, hold otherwise (that once a person is dead, or a person is permanently unconscious, one can do anything one wants to it the person—or corpse--without doing harm). We owe respect to the dead, including the newly dead and the dead who are still on medical equipment whose purpose is to maintain life.

These recommendations might sound cold-hearted, but they are most likely the kindest approach to the bereaved. This is very important to the decision. Most people, when questioned, do want their family's wishes and interests to be taken into account. We cannot ignore that. However in these cases the wishes and interests diverge. As we said in our article: "No one can grant this mother's wish, for her real wish is for the impossible: the return to life of her dead son." (p. 293). When one talks about these issues with the public for years, one senses that most patients would agree to accommodate their family’s wishes, but not for months or years.

None of this proves that there will never be anyone who wants to be kept on a ventilator in a permanently unconscious or deceased state for as long as possible. But that is the exception, the rare exception. It is not our responsibility to adhere to such requests, and that is why most states do not even address the issue, and the few who do leave things ambiguous and only require "reasonable accommodation."

Thus we made some suggestions for reasonable accommodations. For the emotionally distraught family: the patient "should be pronounced dead, and then his family should be informed that all treatment will stop at a certain time (for example, in 24 or 48 hours). They can then choose whether or not to be at his bedside at that time. Their presence is not necessary, though, and their absence should not delay the event (unless they choose a different time of day because of transportation problems). If it adds spiritual comfort, the presence of a chaplain could be arranged, even if the family will not be there. It should constantly be kept clear in communications that the patient has already died, and that all that remains is to disconnect the equipment attached to him." These actions represent responsible fulfillment of the ethical and legal obligation to reasonable accommodation and appropriately respect the family's religious values." (p. 293)

We also stated that we believe that Medicaid and private insurance should not be expected to pay for any care after a patient has been declared dead. We did suggest, however, if a group (e.g. Orthodox Jews) want such treatment, then insurance companies might offer an insurance rider for additional cost to cover the cost of such continued treatment. This might also include long-term care for PVS patients. Even then the number of patients would be low enough that the rider would not be prohibitively expensive. But it would be fairer than making everybody subsidize a religious belief that is neither medically nor ethically justified, and more importantly would give caregivers more certainty that the patient actually wanted this treatment. Having evidence that the patient wanted this would help address the moral distress created by keeping a corpse on a ventilator, sometimes until they begin to rot and smell.

Lastly, we addressed the issue of miracles. This is a frequent refrain one hears in hospitals. And it might intimidate some ethicists as well as many doctors. Does being ethical and culturally sensitive mean we must bow to the beliefs of every family? We suggested that most references to miracles in these contexts are actually "an admission that the odds are very long and that the petitioner is emotionally overwhelmed. It is not time to retreat out of fear of theological depths beyond the reach of doctors' understanding. may be an invitation to talk realistically and to give the family direction." (p. 294)

One sometimes hears the plaint that ethics relies too much on the Principle of Autonomy, and has deserted families in need of kindness, understanding, patience, and a recommendation based on their best interests. I have never been convinced that Autonomy should be such a bogeyman, if indeed any of these accusations about physicians are valid. But regardless of the cause, the answer is not to let families make terrible decisions that will, in truth, only lengthen their period of grieving (potentially by months or years). Keep the focus on what the patient would want, given the medical realities. The answer, given by intensives every day in ICUs, is to listen patiently and then advise wisely. Give the family as much time to prepare as possible (i.e. as soon as you suspect death has occurred or is imminent), and then give them as much emotional support as possible (i.e. having a Chaplain or Rabbi at the bedside when the ventilator is turned off).

Those ethicists who wish to gain the benefits of "Narrative ethics" should not be afraid to make normative recommendations. The word "narrative" need not mean "descriptive." I would rather see narrative taken to mean giving a fuller picture of the persons involved, so we understand them better before we make recommendations. But the purpose of getting to know them better--the "narrative"--is to make better recommendations--the "ethics."