Michael Trimble

Recently I had to have a few minutes in my office to regroup after I’d seen a patient. I didn’t quite know how to process my feelings. I was feeling ashamed and upset. My patient had been in our waiting room for over 18 hours. He was a bilateral amputee and a wheelchair user. His medical problem was not life threatening and easy to treat but was affecting his arm and so affected his ability to care for himself, hence the need for admission. He was usually normally independent, worked full time, headed up a local charity but now suddenly found himself incredibly vulnerable. He’d not want to make a fuss and he was unable to get out of his wheelchair to get to a toilet. He had been incontinent and had no food or drink for fear of needing the toilet again. As I took him into a room to assess him, he grabbed hold of my hand, sobbed and begged me not to abandon him in “that place”. I couldn’t look him in the eyes, I was so ashamed of how we’d treated him this far. After a heart felt plea to the nursing team on AMU we managed to get him into a bed space that had just become vacant. As we undressed him, myself and the nurses were horrified how he’d already got excoriations from sitting in urine in his wheelchair for 18 hours. His story is one of many happening all over the country. We all know how hard it is to sit in a waiting room for hours when transport gets delayed etc, but this is people who are unwell, in pain and already suffering. The ED waiting room is a difficult and busy place to be. The corridor where patients wait is a busy chaotic environment with very little dignity. Both these areas are exactly the opposite of where we’d want our patients to be and almost the perfectly designed area to promote delirium. How do staff feel when they are faced with this? I talked about this recently at a Society for Acute Medicine conference in Belfast and lots of people spoke to me privately afterwards. All had some story where they had experienced something that had left them with similar emotions, of anger but also shame, guilt, embarrassment and failure. One doctor told me that they hadn’t had a DNAR conversation with the patient as they felt that the corridor wasn’t an appropriate place. There were visibly upset as they described arriving at a resuscitation attempt on this frail patient who had clearly been dying. One doctor told me that a patient had asked them to go to the toilet and they’d spoken to the nurse. When they later returned to take more blood tests the patient was sobbing in distress after being incontinent as the nurse hadn’t yet had time and they felt wracked with guilt. Another told me that they’d taken time off unwell and had now agreed not to see patients outside of the ward anymore as it had just become intolerable.All UK based doctors will be familiar with the GMC’s instruction to ‘make the care of your patient your first concern’. Care is an interesting to word; it can mean to care for others or a degree of troubling anxiety, as in ‘worries and cares’. This ambiguity goes as far back as the word’s Latin origins in the 1st century AD.1 It is ironic in the setting of 21st century health care to find that those who try to care for others are so burdened in their endeavours. Why should this be so? For most of us, from the day we enter medical school, and often long before, we hope to do something good, something to help people. At medical school and during training we are encouraged to ‘aspire to excellence.’2 But then in our working life we find that the systems and structures of our institutions do not allow us to do so. Instead of aspiring to excellence, we instead find ourselves working with the normalization of deviance.3 This term was coined by sociologist Diane Vaughan when reviewing the Challenger space shuttle disaster. She used it to describe a situation where people within an organization become so accustomed to deviant behaviour that they don’t consider it as deviant; even though they far exceed their own rules for elementary safety. With safari ward rounds, patients in outlying wards, boarders, and corridor beds now so routine practice as to be unremarkable, we are surely living with the normalization of deviance. There is tension between how we wish to practice and how we actually practice. Moral dilemmas arise when a caregiver must choose between incompatible courses of action, each of which has ethical justification; moral distress is the psychological impact which arises when the agent is clear about the ethically appropriate course of action, but institutional constraints make it difficult to implement.4 Beyond this is moral injury – the point is reached where individuals who are exposed to events that violate their moral values experience severe distress and even functional impairment.5 Though less often discussed than individual or professional ethics, institutions too have their ethical attributes.6 Pellegrino and Thomasma contrast commercially driven health care systems with those based on fiduciary trust and note how this can influence the practice of the clinicians working within.7 We could add to these bureaucratic systems, with a focus on the achievement of certain targets and this is perhaps more representative of the UK situation. What can we do to change this? Ideally, a change in working environment and practices is required. We need adequately staffed units with the physical and functional capacity for the work that is to be done. The Society is lobbying for this at every opportunity. As has been highlighted in recent political debate the model of healthcare delivery needs to be reviewed. However, even with political will and a well thought out plan, this is a long-term matter. In the meantime, we must support each other. So, how can we help each other? Somebody reaching out with kindness and compassion can be essential. The most basic act of listening to someone with cup of tea may sound painfully old fashioned and British, but it is understated in its importance – allowing someone some time to help someone else make sense of their feelings. As outlined above, when faced with these working conditions, individuals can experience a wide range of emotions and may not even recognise they are struggling. In a system where there is an increasing number of patients in increasingly more areas with increasingly more paperwork and administration, time is one thing that is increasingly hard to find, but yet it is so important to allow ourselves and others time to process our experiences. As leaders we should be providing a role model in listening to concerns and providing support whilst simultaneously continuing to raise these issues. As well as looking at what is provided by the local trusts, some people prefer to seek help elsewhere. The BMA offer counselling and support services for doctors across the UK.8 NHS Practitioner Health offers support for doctors working in England.9 In the devolved nations there is the National Wellbeing hub in Scotland,10 Canopi in Wales,11 and trainees in Northern Ireland can access support through NIMDTA.12 References Full Text File size: 115 KB Downloads: 321