Recognizing and relating to a patient’s emotions

Excerpted from “Should Your Doctor Cry With You?,” U.S. News & World Report. July 2, 2014 — Doctors deal with intensely emotional situations every day, in the face of which they are taught to remain objective. But there’s a growing recognition in clinics and medical schools that empathy and emotional intelligence have a prominent place in medicine, too.

If doctors really want to connect with their patients, says Peter Ubel, a physician and behavioral scientist at Duke University, they should model themselves after Starbucks’ employees. Baristas are trained to handle angry customers using the “latte” method of communication, which stands for: listen; acknowledge the problem; take action to solve it; thank them for bringing it to your attention; explain what you’ve done to fix the problem.

Instead, doctors often dismiss a patient’s negative emotions, Ubel continues. Studies have shown that when cancer patients expressed feelings such as ‘I’m in pain’ or ‘I’m scared,’ their doctors – mostly experienced oncologists – said nothing or changed the subject. But simple acknowledgment of the patient’s feelings – with something like "Oh, I can understand why this must be scary for you" – can open up an emotional channel that improves the relationship as well as, potentially, clinical outcomes.

At the same time, the distance that doctors are taught to maintain from patients is important to uphold. “You don’t want your doctor blubbering around the hospital,” Barron Lerner, an internist and professor of medicine at New York University School of Medicine, says. “There’s a professionalism associated with being able to deal with profoundly emotional situations in a dispassionate manner.”

Commentary

Founder, Executive Director and Psychiatrist at Lighthouse Network Karl Benzio, MD: “The Hippocratic Oath is profound in its message as it is a spiritual covenant to hold as the utmost priority the best for the patient and not the best for the healthcare professional or any other third party. ‘The best’ for the patient pertains to the ultimate spiritual and psychological benefits, as Hippocrates said he would not perform an abortion or euthanasia, which would prioritize the physical over the psychological and spiritual.

“Physicians have expertise and healing to impart to patients, but unless a bridge exists to reach patients, healing will be delayed, compromised or not delivered at all. The bridge is relationship, not only doctor-to-patient but also human-to-human. The first step in building this bridge requires communicating understanding, sensitivity, respect, dignity and honor. This is why healthcare professionals ask probing questions, and our demeanor while patients respond allows them to invite us into their pain. Our responses of sympathy and empathy show we are listening and feeling the hurt, fear or uncertainty that can deeply harm them.

Resources

Grace Prescriptions – Learning How to Share Your Faith in Practice
Moving Beyond Physical Healing by Dr. David Levy

Assisted suicide advocates make their case in JAMA

Editor's note: Under JAMA's Conflict of Interest Disclosures, each of the authors of this excerpted article "report consulting for Compassion and Choices," an assisted suicide advocacy organization formerly known as the Hemlock Society.

Excerpted from "The Changing Legal Climate for Physician Aid in Dying," JAMA, April 14, 2014 - Voters in Oregon and Washington have legalized aid in dying by public referendum, legislators in Vermont have done so by statutory enactment, and courts in Montana and New Mexico have done so by judicial rulings. Support for aid in dying is increasing, and it would not be surprising to see voters, legislators, or courts in other states approve the practice.

At one time, it was not clear whether patients could hasten death by refusing life-sustaining medical treatment. Recognition of the right to refuse life-sustaining care reflected a societal consensus that people should be able to decline treatment when they are suffering greatly from irreversible and severe illness. Although a right to refuse treatment did not go too far in allowing death-causing actions, many people felt it did not go far enough. For instance, some patients are seriously ill and suffering greatly from widely metastatic cancer or other advanced diseases, but are not dependent on life-sustaining treatment. For those patients, aid in dying can be an important option.

However, there are real risks if patients are allowed to receive a prescription for a lethal dose of medication. Not all patients who would ask for a prescription would be suffering from an irreversible and severe illness. Some might have become tired of life, depressed, or feel that that their life has insufficient meaning. Accordingly, a right to aid in dying could be recognized only with assurances that access would be limited to patients who are truly seriously ill. In addition, as with the withdrawal of treatment, the government could not impose limits by making quality-of-life judgments.

The terminal illness requirement provides the right kind of limit for aid in dying. It does not empower the government to make quality-of-life judgments, and it restricts the practice to patients who are suffering from irreversible and severe disease.

This is not just a matter of theory. Oregon has had more than 15 years of experience with aid in dying limited to the terminally ill, and the state’s experience has been reassuring. Vulnerable patients are not succumbing to aid in dying. It is not surprising that once Oregon’s experience with aid in dying was reassuring, other states were willing to consider authorizing aid in dying.

By restricting aid in dying to competent and terminally ill adults, the law can ease the dying process for patients, and their families, and avoid the potential for the mistreatment of patients.

Commentary

CMA VP for Government Relations Jonathan Imbody – “These assisted suicide advocates cleverly employ several techniques to break down barriers to their radical position, which is that we should obviate over two millennia of Hippocratic medicine and empower doctors to help their patients kill themselves.

• Employing euphemisms: The authors insist that the euphemistic term ‘aid in dying’ replace the clear and accurate term ‘assisted suicide.’ The group they support changed its name from the Hemlock Society to Compassion and Choices.
• Linking a radical idea to an accepted idea: We're supposed to think that just as our society once hesitated to allow patients to refuse life support but now accepts that notion, we likewise should see the light and embrace assisted suicide. As if there is no difference between letting someone die naturally and killing them with secobarbital.
• Stressing meaningless safeguards: The authors try to position themselves as the concerned, conservative protectors of patients and ethics, emphasizing that ‘a right to aid in dying could be recognized only with assurances that access would be limited to patients who are truly seriously ill.’ But since ‘the government could not impose limits by making quality-of-life judgments,’ who determines what ‘seriously ill’ means? You guessed it--physicians like the authors, whose bias toward assisted suicide will doubtless expand the definition beyond meaning.
• Citing misleading statistics: ‘Figures don't lie, but liars figure.’ Crafty assisted suicide advocates wrote into Oregon's assisted suicide measure the following secrecy clause: ‘...the information collected shall not be a public record and may not be made available for inspection by the public.’ That clause prohibits anyone-- relatives, media, watchdog groups, medical associations--from investigating the details of any of the reported assisted suicide cases. State bureaucrats, who, of course, maintain a vested interest in covering up any problems or abuses that might reflect negatively on the state, annually trot out their own bland, general statistics without detail or the possibility of review. Year after year, assisted suicide advocates point to these meaningless, whitewashed, non-verifiable numbers as proof that the system is working wonderfully.

“For secular audiences, some effective arguments against assisted suicide include:

• highlighting the lack of safeguards in most assisted suicide measures, including inadequate diagnosis and treatment of depression, the absence of requirements to notify family members and the dangers of storing lethal medications at home;
• explaining how assisted suicide perverts the safe nature of the patient-physician relationship, removing the vital assurance that the physician will always ‘do no harm;’ and
• emphasizing that healthcare payers including insurers, the government and even heirs have a tempting financial incentive that leans heavily toward your premature death.”

Resources

CMDA Resources on Assisted Suicide

Action

Write a response to JAMA

Advocate in your own specialty college for hospice and palliative care and against assisted suicide and euthanasia.

Assisted suicide advocates: Bypass physicians for lethal prescriptions

ARTICLE:
Excerpted from "Redefining Physicians' Role in Assisted Dying," by Julian J.Z. Prokopetz, B.A. and Lisa Soleymani Lehmann, M.D., Ph.D. New England Journal of Medicine: N Engl J Med 2012; 367:97-99, July 12, 2012) - Under the Death with Dignity Act (DWDA), the patient's physician prescribes lethal medication after confirming the prognosis and elucidating the alternatives for treatment and palliative care. In theory, however, the prescription need not come from the physician. Prognosis and treatment options are part of standard clinical discussions, so if a physician certifies that information in writing, patients could conceivably go to an independent authority to obtain the prescription. We envision the development of a central state or federal mechanism to confirm the authenticity and eligibility of patients' requests, dispense medication, and monitor demand and use. This process would have to be transparent, with strict oversight. Such a mechanism would not only obviate physician involvement beyond usual care but would also reduce gaps in care coordination: in Oregon and Washington, patients whose doctors don't wish to participate in assisted dying must find another provider to acquire a prescription. Physicians who strongly object to the practice could potentially refuse to provide certification or could even alter their prognosis, but these possibilities yield the same outcome as permitting conscientious objection. Patients could also provide an independent authority with their medical record as proof of their prognosis.

Such a mechanism would make it essential for physicians to offer high-quality palliative care. The availability of assisted suicide in Oregon seems to have galvanized efforts to ensure that it is truly a last resort, and the same should hold true regardless of who writes the prescription. Usual care for terminally ill patients should include a discussion of life-preserving and palliative options so that all patients receive care consistent with their own vision of a good death.

Momentum is building for assisted dying. With an independent dispensation mechanism, terminally ill patients who wished to exercise their autonomy in the dying process would have that option, and physicians would not be required to take actions that aren't already part of their commitment to providing high-quality care.

COMMENTARY:

CMDA Member Mark McQuain, MD: responded to this NEJM article: "Returning to Pre-Hippocratic Medicine - Margaret Mead has been quoted as saying (regarding the Hippocratic Oath), 'For the first time in our tradition there was a complete separation between killing and curing. Throughout the primitive world, the doctor and the sorcerer tended to be the same person. He with the power to kill had power to cure, including specially the undoing of his own killing activities. He who had the power to cure would necessarily also be able to kill...With the Greeks the distinction was made clear. One profession, the followers of Asclepius, were to be dedicated completely to life under all circumstances, regardless of rank, age or intellect - the life of a slave, the life of the Emperor, the life of a foreign man, the life of a defective child...'
"Amongst other things, Margaret Mead was talking about trust between the patient and her physician. Society should not want physicians and other health care providers to be placed in any position where this trust becomes questionable, particularly as other entities insert themselves into the decision-making process. This is particularly the case as physician's conscience protections are being challenged and arguably eroded via federal regulations."

COMMENTARY:

CMDA Senior VP Gene Rudd, MD: "This is 'reasonable' progression of the assisted suicide initiatives. 'Reasonable' in the sense that once you cross the moral boundary of facilitating death, you need only improve the efficiency of the process by removing impediments.

"Some see state laws as the greatest impediments to expanding assisted suicide. Actually, our experience in opposing expansion has shown resistance of the medical community as the most effective impediment. The opposition from individual doctors and state medical societies has been key to thwarting the agenda of death. So proponents of assisted suicide now want to bypass that impediment.

"The article states that the Oregon experience proves there is no slippery slope. However, the author’s proposal for government involvement in order to expand assisted suicide is evidence to the contrary. Since the great majority of physicians refuse to participate or even endorse assisted suicide, the author concludes we simply need the government to step in with a system to assist in dying. That’s all we need, another costly federal program and more bureaucratic control of our health care – or in this case, control of our dying. I used to think it inappropriate to make this comparison, but as I have seen events unfolding, I am compelled by the slogan in the wake of the Holocaust, 'Never again!' We must stop this descent into cultural insanity or the next proposal will be that we establish federal centers where people will be 'referred' for death."