Last week we watched the Frontline episode called Being Mortal. This week please analyze using our reading by Childress & Siegler. What models/metaphors describe most
end-of-life care in America today? Would it be better to use a
different metaphor? Explain.
For reference: http://www.pbs.org/wgbh/pages/frontline/being-mortal/
Childress and Siegler describe a paternal physician-patient relationship being similar to that of a parent-infant relationship. This could be applied to a scenario of end-of-life care if the patient was actively dying and unable to make their own decisions. The family may or may not be involved in the patient's care, therefore the physician would be the decision-maker for the patient. Childress and Siegler also describe a relationship as a partnership. A partnership may involve the physician and patient working equally to establish the patient's goals of treatment. This metaphor seems to highlight the relationship in end-of-life care. Generally, the physician discusses the patient's goals, need, and wishes for treatment, and while collaborating together, they come up with a plan to successfully meet those needs. The family could also be the "partner" involved with the planning, regardless of the patient's level of consciousness (Childress, 2011).
ReplyDeleteReference:
Childress, J., & Siegler, M. (2011). Metaphors and Models of Doctor-Patient
Relationships: Their Implications for Autonomy. In Biomedical Ethics (7th ed.,
pp.74-82). New York: McGraw-Hill Higher Education.
For an end-of-life scenario I would compare to the parent-adolescent relationship. The doctors will talk, educate, and give suggestions to the patient and/or families but then it's up to them to do what they want with it. They can chose to agree with the doctor and go with their recommendations or they can make a different decision for themselves.
ReplyDeleteSo many patients and families don't want to give up the fight at the end and when talking with them they all have different reasons. Some have had a bad hospice nurse in the past and don't want that experience again, others want to live for an upcoming occasion, and some believe and miracles and feel that if they chose comfort care measures then all hope is gone.
Shelley,
DeleteThe sad fact is that one bad experience will produce much negative feedback. I still meet many people that don't even want to say Hospice because they think it is a death sentence. I had a patient once that agreed to place his wife in Hospice care but all staff was under strict orders not to say "Hospice" in the patient's presence or look at her feet and legs (because she knows what you are looking for).
That is so sad Cindy. I really enjoy working with hospice patients and their families. Its always hard when you lose one of your patients but it feels great to know that you helped them. I still feel it is difficult to start the conversation of hospice with patients.
DeleteShelley I agree with you about how patients have a good reason to chose treatment over hospice care. Hope is all they have. If they give hope up they feel like they didn't fight. Also most patients I take care of state what you stated they have one more thing they want to do in life.
DeleteChildress and Siegler talk about the physician/patient relationship as a partnership. I think this would be a good model for those patients dealing with end of life decisions. Partnership emphasizes that the physician and the patient are equal in the equation and the respect for autonomy is the biggest factor. This is also known as "the adult to adult" relationship.
ReplyDeletePatients should feel that they are apart of their treatment process, that they have a say in what they want to do. The physician's role is to guide the patient and give them available options. Communication between the two parties is priority, so that they are on the same page with each other.
I think the partnership aspect of Childress and Siegler's model is the ideal when it comes to end of life care, unfortunately I have seldom seen it . Sometimes its because the end of life is sudden, sometimes because the patient and physician disagree on the course of care. I think as healthcare providers we are not being proactive enough in addressing these issues early and frequently as patients progress throughout their lifetime. Wouldn't it be wonderful for our patients to be well informed and us in turn to know their wishes so there is no question and delay n comfort measures if that what is truly wanted? I think palliative care will be a much bigger part of health care in the coming years.
DeleteEnd of life conversations need to be taken place much sooner than we are currently seeing in practice today. Usually the patients are so close to death before entering hospice. I thinks it's very unfortunate because hospice has so much support to offer not only the patient but to the family too. I think that's part of the reason some people say the had a "bad" experience with hospice. They actually believe hospice "killed" their loved one because they died so soon.
DeleteTricia you hit the nail on the head by saying the physician is there to give available options and to guide the patient with their choice.
DeleteI agree that whatever phase of the model the Patient and Physician is in the key is communication. That way support is given with whatever the Patient's needs are.
DeleteI agree that whatever phase of the model the Patient and Physician is in the key is communication. That way support is given with whatever the Patient's needs are.
DeleteIn the reading from Childress and Siegler similarities of relationships are shown to scenarios of end of life care. In a Physician-patient relationship the two work together to make the best decisions for end of life care. Goals are made together and plans are discussed together. “the best compromise between the ideal of partnership, with its emphasis on both equality and autonomy, and the reality of medical care, where mutual trust cannot be presupposed” (Childress, J., Siegler, M.,Pg. 78)
ReplyDeleteEnd of life care is always very hard for families and patients on decision making. To be able to partner up with your doctor and have help with these decisions on what would be best for the patient would be best.
Reference:
Childress, J., & Siegler, M. (2011). Metaphors and Models of Doctor-Patient
Relationships: Their Implications for Autonomy. In Biomedical Ethics (7th ed.,
pp.74-82). New York: McGraw-Hill Higher Education.
Andrea,
DeletePartnership is important, however, many physicians struggle with this. The family, nursing and social worker have equally important roles in supporting, educating and giving information. This is the true partnership.
Cindy
I think in the video that we watched that their was a couple of different relationships. the first being the partnership. In this I think when the patients are making their decisions and discussing this with the drs that this is a partnership. I feel like that patients need to feel like they are in collaberation with the dr's in discussing and making decisions in their care. I feel like the dr turns more into the parent when the patiens is actively dying. The patient can't make the decisions and the family may not be able to so the dr is the "parent" and makes the decision.
ReplyDeleteI feel like these metaphors are good analysis of the patient/dr relationships. I feel like that all 5 apply at certain times of the pt/dr relationship.
I have been teaching about autonomy, paternalism, and dr-pt. relationships for years, but it is only just now occurring to me that the models rightly shift depending on what the medical situation is. While I am a big proponent of autonomy, having worked with hospice and thought a great deal about death & dying, I'm starting to lean more towards a paternalistic-flavored dr.-pt. model for end-of-life care. You'd have to have well-trained docs, certainly, and they'd need to be somewhat compassionate. Or at least they'd have to know how to work as a team if they aren't good communicators themselves.
DeleteThat is an excellent point Sherry! After reading your blog, I 100% agree with you. There are stages that most people go though about death and dying and all theories mentioned can apply.
DeleteI think in regards to end of life care, the relationship becomes that of paternalism. The physician assumes the role of caring parent while the patient and family function as the child or children. In my most recent experiences their always seems to be a moment when no matter what has been decided prior , there is a moment at the end of life when the family needs the guidance and reassurance that they are doing what is right for their loved one. They almost need that loving reassurance that its ok to let them be comfortable, to stop pursuing treatment.
ReplyDeleteWhile I think that the model of paternalism most applies here, certainly some element of all 5 models must exist to build a solid caring relationship with the patient and family and furthermore. at different times, different models could be used.
"a moment at the end of life when the family needs the guidance and reassurance that they are doing what is right for their loved one. They almost need that loving reassurance that its ok to let them be comfortable, to stop pursuing treatment" Yes -- that's it exactly, "loving reassurance" and if the doctor isn't great at doing it, then perhaps s/he can approach the family with a nurse, social worker, and/or chaplain to provide that support.
DeleteWhen comparing Childress and Siegler models for the physician-patient relationship to the Frontline episode, Being Mortal, many similarities are noted. I can see an aspect of all 5 models in end-of-life care in America, but I feel that the most used model is that of partnership. Partnership between the patient, family and physician was evident throughout the film.
ReplyDeleteI also felt like all five models could have a little part in making the decision for EOL It is very true there has to be a partnership between the patient, the physician and the family to have the same goal in common. We often see that not all are on board with what their loved ones might want which then creates another issue in itself.
DeleteI also agree with different aspect of the models applying to the situations. It's very hard to grasp at the relationships of the Patient and the Physician for the death and dying process as we are not the participants but the observers. We just know what we see.
DeleteI also agree with different aspect of the models applying to the situations. It's very hard to grasp at the relationships of the Patient and the Physician for the death and dying process as we are not the participants but the observers. We just know what we see.
DeleteI agree with partnership because both sides depend on one another to be honest and communicate openly with each other about prognosis and wishes. They would not be able to make decisions without the right guidance and I don't think appropriate guidance can be given if the wishes of the patient are unknown.
ReplyDeleteIt is teamwork between the patient and physician and hopefully also the family if the patient will allow. The ultimate goal is to reach the best decision for the patient with the open and honest communication being key to an optimal outcome. We as nurses are in a prime position to encourage, gently and at the right time, our patients to talk to their family and doctor about what they want at the end of life.
DeletePaternalism seems to be relevant with the physician and patient relationship. All five would be relevant, but paternalism is my choice. The patient needs to feel it is okay to let go and the physician and family need to say it is okay. Many times the nursing staff is left to provide this guidance. I believe many physicians stubble with this.
ReplyDeleteEnd of life issues are always tricky and sensitive no matter what. I believe the best model to describe most end of life care is the parent-adolescent child relationship. In this role, the physician takes on a parental type control, explaining to the patient what the best options are and what to expect as the end of life nears. The physician in this role is typically very caring and concerned and has the patient's best interest at heart. The patient on the other hand still has the autonomy to accept or reject what the doctor is telling them to do. They likely are facing something they never knew before, need guidance, and therefore need the doctor's input to make informed decisions about their care. In theory I think this is a good model, there are others that fit as well, but may not be as fitting as this one. I can definitely see there could be a shift as the patients condition changes. Like the ballerina with asthma, initially wanted cured but ultimately wanted to still be able to dance. Doctors may be treating end of life symptoms and prolonging life, but potentially making the patient weaker and unable to enjoy what's left of life. I believe there are aspects of negotiation within all types of physician/patient models. Ultimately, there has to be some sort of trust on both ends in order to have a successful doctor/patient relationship and definitely a lot of communication as things progress.
ReplyDeleteI agree with you Carla. The doctor and not focus anybody to do what the doctor thinks is right. All the doctor can do is give the best advise and what the patient or family member does is totally up to them.
DeleteChildress and Siegler theory describes partnership relationship as collaboration between the physician and the client. The relationship between adults, that defines a of set mutually agreed goals. and autonomy is present. The video demonstrated this relationship with the end of life care.
ReplyDeleteI believe honesty, autonomy, and essential for end of life decision making between the physician and patient. Partnership is the key to success!
The partnership as described by Childress and Siegler is what I think is not only an appropriate end of life relationship, but a relationship I would like to have with my physician. In partnerships, such as in business, with co-workers or even marriage, there is typically a common goal. Each partner brings a different point of view of how the goal should be obtained. In a good partnership, each partner has the ability to listen to the other. I think in the video this relationship was emulated with the male patient and the multidisciplinary team caring for him, but especially with his physician. He clearly was not ready to die from his brain tumor and had done research on experimental treatments. When he asked about this, she did not say that it wouldn’t work, but that she would look into whether he was a candidate. In partnerships we give those we are in relation with the courtesy of listening to their opinion. The physician in turn, was very honest with him as to how she thought the cancer was progressing.
ReplyDeleteI think that there is a bit of contract relationship in all Dr./Patient relationships. By virtue of the fact we have made appointments with and paid the physician. When we have that initial conversation with our doctor stating our reason for the visit, regardless of whether it is a well check or to address a problem, we have initiated a contract to either address the problem or verify our health status.
I think a relationship of friendship would be draining on the physician. As a patient many of us would like to think of our physician as our friend. For the physician to make decisions and have the type of concern we expect from a friend would put physicians at risk for early burnout.
I believe the parent-adolescent child relationship is the best model to describe end of life care. Even when the patient becomes to weak to talk or make their own decisions the MD still looks to the family members as to make decisions relate to care. It is up to the family members or patient to make their own decisions while listening to the advice of the doctor and other heath care members.
ReplyDeleteI believe that the end of life talk should happen much soon then it does in most families. Even though the talk is hard to have with your love ones, I think that every family member should know what their family member will what in these type of situations. I think it will also decrease so of the stress if the family members know what their love one would want.
I agree the talk about what someone would want at EOL should take place much sooner. I see that for many terminally ill patients who do discuss what they want at EOL lifts a burden from their family to make those decisions. It is almost as if it puts them at peace.
DeleteI also believe that conversations about the end of life should be happening much earlier than they are. Patients who utilize Palliative care may live longer than their counterparts who continue aggressive treatment. And those opting for palliative care may have better control of symptoms and better quality of life. Those are very difficult conversations and physicians with a model of partnership type care may be able to more easily begin those discussions.
DeleteI agree. There is a point where the treatment is worse than the disease itself. Patients should have the option for all avenues of treatment and then make fact based decisions.
DeleteThe physician-patient metaphor I believe describes how patents make choices and reacts to the treatment they are put on by their physician. If it is going to alter their life style and hinder with their life desirers they start to question is the treatment worth it? The physician would claim yes it is worth it but, the patient has the right to what they want out of life. Even if this means their health will be compromised they may feel it is worth the risk. Autonomy should be respected.
ReplyDeleteI believe that there may be more than one of the five models of the doctor-patient relationship involved in making decisions for EOL care. When they discuss paternalism it does paint the picture of the physician wanting to take care of and do for the patient as a parent would of their child. In the video the surgeon wanted to not only protect and do what he thought was best for the patient he wanted to do what was best for her husband and newborn. He knew that the experimental drug probably would not help her but he did not want to take away her and her families hope. Is was almost as if he was also hoping for a miracle. Then I also think there is definitely a partnership between the physician and his patient. They have a common goal, they both are hoping for a treatment that could cure the disease or at least give her more time with her family. The physician definitely bonded with this young family, developed a friendship. I think in a way the friendship and his personal feelings got in the way of him informing the patient about how sick the experimental drugs could make her and how her last days would not be of good quality where she could enjoy her family but that she would become very sick from the side effects. A patient wants the physician to help them make decisions. It is true that autonomy should be valued, but how can a patient make an informed decision without the truth of the risks vs the benefits of a treatment. Some would rather view quality of life rather that quantity of life. Although it is hard to say unless you are in the situation to have to make a decision, would you rather live a good quality of life being able to still function somewhat for what ever day there is left here on this earth, or would you rather live longer but be deathly ill and unable to enjoy the rest of the journey of life.
ReplyDeleteBeing mortal really makes look at how death and dying is perceived. Why are the physicians so hesitant to talk about death and dying and what someone wants as during their last days.
I believe the the end of life process today in America uses a few of the metaphors described in the readings. The Physician and Patient relationship changes as the end of life process changes. They start with the initial meeting and discuss the committment each will make and their interpretations of the agreed upon goals. This is the contract phase. Next is the partnership phase. As two adults the outcomes and goals within the relationship become equal. With this is the mutual understanding. And finally, I believe, as death nears, a form of paternalism is achieved within the relationship. The fear of dying makes the Patient vulnerable and gives the Physician the role of the parent. This is how I have seen many end of life event occur in the ICU. So I don't think it is just one metaphor but a family of metaphors that assist with the Physician and Patient relationship with regards to the death and dying process in America.
ReplyDeleteI believe the the end of life process today in America uses a few of the metaphors described in the readings. The Physician and Patient relationship changes as the end of life process changes. They start with the initial meeting and discuss the committment each will make and their interpretations of the agreed upon goals. This is the contract phase. Next is the partnership phase. As two adults the outcomes and goals within the relationship become equal. With this is the mutual understanding. And finally, I believe, as death nears, a form of paternalism is achieved within the relationship. The fear of dying makes the Patient vulnerable and gives the Physician the role of the parent. This is how I have seen many end of life event occur in the ICU. So I don't think it is just one metaphor but a family of metaphors that assist with the Physician and Patient relationship with regards to the death and dying process in America.
ReplyDeleteWe have come a long way in treatment of diseases and illnesses leading to a longer life span. Treatments and medications allow extended lives. I think that if a patient has had the same physician for a number of years, the relationship may be that of a partnership with end of life care and matters. However, with many patients cared for by a hospitalist while hospitalized, I find it harder to believe that the patient would feel the same "partnership" that they may have with their own physician. That is not meant as a negative comment towards our hospitalists because I believe a few of them have a great deal of compassion and ability to develop that partnership. I think that the metaphor or model can fluctuate.
ReplyDeleteIn the movie Being Mortal in relation to the readings by Childress and Siegler, I believe the relationship the main character had with his patients began parental in nature. He made the decisions or convinced the patients to follow his decisions by not revealing all of the facts to them.As the story evolved and he had follow up conversations with his deceased patient's family members and went through the loss of his own father his model changed to partnership.
ReplyDeleteI believe that partnership is the best model to use when practicing medicine. I believe that the patient should be informed of all of the facts and treatment options with coinciding outcomes. The physician and medical staff should not lie to the patient or conceal truths to protect the patient from their own disease. If the MD or RN is asked what they feel the best option would be at that time they could give their thoughts.
I see a CA patient on a weekly basis who is not expected to live to see the end of the year. He had an appointment with his oncologist and a new medication was added to his regime due to his cancer was progressing. The patient was not aware that his cancer was progressing. When he asked me why they had added this new medication I had the difficult job of explaining the truth. The truth he states his oncologist, who I have great respect for as a physician, did not tell him. It was hard for him to hear and hard for me to tell him. After words we were able to review the options such as a hospice referral or plans to continue the treatment. He was also able to verbalize his grief that he was dying. He said he had been holding this in for several months. After this talk the weekly visits have been more focused on how he can live life to the fullest while he is able as well as his medical needs.
Nicole: thank you for stepping up and delivering that hard news.
ReplyDeleteAll: really nice discussion about the variance in models, depending on the pt. condition, type of doctor, and background relationship between dr. & pt.