Rosemary Frey

Lawrence Powell

Merryn GottPhoto: Phillips (2011)

Mensagitatmolem - The mind moves matter.

–Vergil (BC 70-19)

Goal:

• To explore and describe the

components of both the

biomedical view and the holistic

view of palliative care.

Definitions

• Palliative – ―to cloak‖ (OED, 2011)

• Palliative care - originally used to describe patients with chronic or terminal illnesses (Balfour Mount)

• Worldview - A more or less internally consistent set of orientations to the social world—encompassing cognitive, affective, and normative perceptual predispositions (Frey & Powell, 2005, p. 119).

Bio-Medical Worldview

• Its way of thinking is distinctly analytical

and rationalistic. Clinical concerns are

approached as puzzles to be solved;

clinical encounters are treated as

occasions for scientific inquiry.

Because the object of analysis is the

disease and not the patient, symptoms

are treated as clues to

diagnosis, instead of phenomena that

are themselves worthy of treatment

(Fox, 1997, p. 761).Art: Fundraw (2006)

Holistic Worldview

• Whereas the biomedical model is primarily analytical, the holistic model is as much hermeneutic as it is analytical. Ideally, understanding total pain thus requires entering the patient‘s psyche, history, culture, beliefs, and social relations. This means not only observing but also asking about and interpreting the meaning of what she or he has lived through (Mino &Lert, 2005, p. 228).

Photo: Travers (2011)

Design and Sample

• Case study design in one New Zealand

acute hospital

• In-depth interviews with 7 physicians

involved in generalist and specialist

palliative care provision

• Topic: explore barriers to, and facilitators

of, good palliative care management

Data Analysis

• Created two composite text files (Biomed/Holistic) using

Hamlet (Brier, 2003)

• A 50-word sample of most frequently used words drawn:

word usage for each participant type

(Biomed/Holistic), was expressed as a percentage of the

total words in the 50-word sample

• A Multidimensional scaling representation of the 35

words × 2 participant-types matrix, in two and three

dimensions, usingWordProx(Powell, 2011)

• Text quotes illustrative of both types were selected

based on the results of the analyses.

Demographics

• Gender: 6 male, 1 female • Specialities :

Age

Lowest

to 39

1

40-49 3

50-59 2

60 and

over

1

Emergency

Colorectal

1

Intensivist

1

Oncology

1

Renal

1

Geriatrics

1

Emergency Med

1

House Officer

1

Biomedical Worldview Participant

Holistic Worldview Participant

Definitions of Palliative Care

Biomedical

• Palliative care is care for the

patient whose disease is not

curable, so the patient will

die from the results of the

disease and it‘s futile to

attempt or to have the

illusion of fixing that

particular problem.

Holistic

• No, it's not the end of their

life – Well that‘s the

paradigm which people

have, I think, become

constrained to by the use of

these words, that these two

issues are temporarily

separated. That we have

treatment and then we

have, uh-oh, it's all failing,

the patient‘s dying, now let‘s

have palliation or end of

life....And therefore if you

think of something which

needs to go on

simultaneously with active

treatment...

Life and Death

Biomedical

• We stop people dying of vascular deaths and then they go on and die of worse things really. I mean there‘s something not too bad about a big heart attack or a big stroke that kills you relatively quickly rather than dragging it out and having a slow painful cancer death.

Holistic

• A lot of patients with what

we might have thought of

as inexorably fatal

malignant conditions

often live for many, many

years in good health

whilst receiving intensive

treatments of various

kinds.

Treatment

• Biomedical

• No, I can‘t have a patient who dies, my patients don‘t die, you know? I‘m exaggerating but there is that sort of thing. And some people are, you know, they‘re uncomfortable or feel inadequate if the patient doesn‘t have a course of treatment that makes them better. You know, they feel that they might have failed.

• Holistic

• Once you‘re in the emergency room the YUHAFTI syndrome starts –you have to do everything... But in fact whether you can or can‘t fix it is irrelevant to whether or not you should or should not fix it. And that moral question is never considered.

NeedsBiomedical - symptoms

• So that they‘re still continuing with an active treatment but have got some other condition which is causing them ongoing pain or discomfort or some other symptom. For instance they might have peripheral vascular disease which might be untreatable so they‘ve got ischemic pain or ulcers on their legs or might‘ve had a stroke or ongoing angina or a cancer or something.

Holistic – whole person

• The doctor has to bring not just their technical skills but they must bring humanity to that person as a human being. Therefore you have to get involved in matters of the nuances of illness as being a threat to their survival and as a threat to their wellbeing and quality of life, and you have to acknowledge those things and maybe address that.

“Care or Caring”Biomedical

• So we would try to set

that up beforehand, so I

guess that‘s end of life

care-planning or

advanced care planning

and then the actual active

palliative part might be

much later down the line.

Holistic

• At the present time we have

this archaic model where

patients with complex multi-

disciplinary problems are

admitted under the care of

what we call SOD, Single

Organ Doctor, who focuses

on the single organ, not

even the patient. And not

even, nothing remotely like

their palliative or comfort

care needs.

Appropriate?

Biomedical – Failure to

Plan

• They just waited for a crisis to happen and then they‘d all pitch up in the hospital…other people who come inappropriately because there‘s not a plan sorted out because it hasn‘t been addressed by their teams and a lot of people are in that situation.

Holistic - Physician

Attitude

• Doctors are very reluctant to

give appropriate

professional

recommendations anymore.

‗Oh I don't do that, I just lay

out the options like an a la

carte menu and then you

tick, do you want the

fries, do you want the

garammasala, whatever you

like. You pick, I'll just do it‘.

Discussion

• Why hesitance to change?

• Success of medical reductionism – scientific advances in health

• Lack of time –

Biomedical View Participant:

• I mean I'd like to have lots of training in lots of different areas but it‘s the practical issue of can I do it. I'd like to know about the resources but I probably don't want to spend a lot of time doing it. I mean I have to do my own job.

Discussion

• Money matters –

• Biomedical View Participant:

And if an item is reimbursable, then it's an appropriate way to spend time. If an item such as family discussion, end of life care family discussion, might take 45 minutes of a patient care interview, well during that 45 minutes I could‘ve done three 15-minute billable procedures.

Recommendations

• Attitudes, beliefs, and self-perceptions

underpin behaviour and thus practice.

Therefore the worldview held by a clinician

may either support or create barriers to

holistic care.

• Hospitals also need to provide a context and

resources, such as additional communication

training, appropriate settings as well as

personnel to facilitate a more holistic

approach to medical practice Alonso (2004).

• To hold together in one and the same

medical act both the reductivist scientific

truths that are so beneficial and also the

larger truths about the patient as a human

person is the really enormous challenge

health care faces today (Sulmasy, 2002, p.

25)

Photo: Lily Holistic Centre (2011)

References

• Alonso, Y. (2004). The biopsychosocial model in medical research: the evolution of the health concept over the last two decades. Patient Education and Counseling, 53, 239-244.

• Brier, A. (2003). Analysis of joint frequencies of words in a text. Southampton.UK: University Computing Service.

• Fox, E. (1997). Predominance of the curative model of medical care: A residual problem. JAMA278(9), 761-763.

• Frey, R.A. & Powell, L.A. (2005). Beyond left-right ideology in the study of justice perception: Interdependent and independent distributive worldviews in Jamaica and New Zealand Journal of Cross-Cultural Psychology 36(1), 117-146.

• Fundraw (2006). ―Caduceus‖ Retrieved from: www.fundraw.com/clipart/clip-art/2327/Caduceus/

• Lily Holistic Centre (2011). ―Reike‖ Retrieved from: www.lilyholistic.com/reiki_i0f2.png

• Mino, J. C. &Lert, F. (2005). Beyond the biomedical model: Palliative care and it‘s holistic model. HEC Forum, 17(3), 227-236.

• Oxford English Dictionary (OED) (2011). “palliative.” Retrieved from: http://oxforddictionaries.com/definition/palliative

• Phillips, D. (2011). “Worldview” Retrieved from: wdavidphillips.com

• Powell. L. (2011). WordProx. [computer software]. Auckland: University of Auckland

• Sulmasy, D. (2002). A biopsychosocial-spiritual model for the care of patients at the end of life. The Gerontologist, 42(iii), 24-33.

• Travers, M. (2011) . Image #101725, Illustrator #0111 . Retrieved from: http://ClipartOf.com/101725