About Care, Palliative and Integrative Care and the Quality of Presence: Selfcare, Empathy and Trust
Anna Alice Amorim Mendes *
Department of Health and Society, Fluminense Federal University, Brazil
Submission: November 30, 2018; Published:January 18, 2019
*Corresponding author:Anna Alice Amorim Mendes, Institute of Collective Health, Fluminense Federal University, Estrada Washington Luiz, 520 ap 126, Sapê, Niterói, RJ, 24315-375, Brazil
How to cite this article: Anna Alice Amorim Mendes. About Care, Palliative and Integrative Care and the Quality of Presence: Selfcare, Empathy and Trust. Palliat Med Care Int J. 2019; 1(4): 555570. 10.19080/PMCIJ.2019.01.555570
Abstract
The article comments on the unbalanced condition of contemporary medicine, regarding scientific development and quality of care, clients’ needs and demands and professionals’ resources, and situates this picture inside the frame of the odd culture of care in contemporary Society. Some aspects in palliative and integrative care are identified that may contribute to improve the quality of health care in all areas, and we name them together as ‘quality of presence’.
Keywords: Concept of care; Palliative care; Integrative medicine; Quality of presence; Selfcare; Empathy
Introduction
Most people are not satisfied with quality of health care, in public and private services, even in developed countries. When a physical curable disease is found at one’s body, and one do have access to the necessary resources to treat it, patient and doctor will feel fine. But when the symptoms cannot be figured out as a known syndrome, or when there is no possible cure for an advanced disease, doctor will feel impotent and patient will feel abandoned.
21st-century medicine is usually described as highly specialized, technological, scientifical, and also as having lost its supposed humanitarian character. Under anatomical and biochemical paradigms, it seems that medical knowledge turned out to be more important than medical care. The question is: why such a fantastic scientific development is not being followed by a proportional improve in the quality of care and satisfaction of the clients? By the end of the 20th century some medical models were proposed as attempts to counterbalance the big emphasis on quantitative, objective and generalized knowledge imposed by the mainstream of evidence-based medicine. Narrative medicine, patient-centered medicine, integrative medicine have been struggling to bring the patient, as a whole being, back to the center of the health care scene.
But despite their reasonable arguments and simple propositions, these models did not impact medical practice as they should. Medical doctors are living under great stress, associated with lack of stability, overload of information, excessive hours of work, patients misinformed by media, insufficient resources, lack of control over their work process, and most professionals feel unprepared to deal with emotional and spiritual demands of patients and their families. Palliative care is probably the area where the needs presented by the patient and the care offered by the health workers have happened to match. What dimensions of this quality of care can possibly be extended to other areas of medical and health care practices?
About Care in Contemporary Society
Contemporary Society defies health professionals with an odd challenge: an enormous demand for care and an equally big disregard or unwillingness to care. Never before did people consume so many acts of care for every dimension of life: experts will take care of one’s physical activities, of one’s diet, of one’s prayers, of the education of one’s children, of one’s dogs, will set in order one’s closets, financial matters and even daily schedules. At the same time, we witness an astonishing lack of care – for oneself, for others and for the environment. Most people are willing to pay for some health and healing in the form of a magic pill or a weekend in a spa, but do not feel ready to undertake any changes in their daily habits.
Social scientists describe a moral and ethical crises in Society, leading to a devaluation of life itself and a looseness of bonds among people and between people and institutions, generating a kind of diffuse malaise or forlornness. This might help to understand the augmented frequency and range of needs and demands for care that are being addressed to health services and health professionals. Every suffering can be translated into physical and mental symptoms in order to be accepted as a health problem and so deserve professional attention and care. But are health professionals ready and willing to deal with all these demands, that include not only physical problems, but also Abstract The article comments on the unbalanced condition of contemporary medicine, regarding scientific development and quality of care, clients’ needs and demands and professionals’ resources, and situates this picture inside the frame of the odd culture of care in contemporary Society. Some aspects in palliative and integrative care are identified that may contribute to improve the quality of health care in all areas, and we name them together as ‘quality of presence’. Keywords: Concept of care; Palliative care; Integrative medicine; Quality of presence; Selfcare; Empathy emotional and spiritual needs? How can we develop an adequate quality of health care in a Society with such a fragmented and odd culture of care?
Concept of Care and Care of the Self
Care is not only a constitutional dimension of medicine and health care; it is a central dimension of life. According to Heidegger [1], “Care (Sorge) is the Being of Dasein”, the nature of human being, the fundamental structure that underlies each and every particular human existence. Dasein is related to the verb Sorgen (to care) in two ways: occupation (Besorgen), ahead-of-itself, being-already-in-the world, and preoccupation (Fürsorge), being-alongside-and-caring-for-others. We can only exist and be in the world and in relation to others. Frederic Worms [2] also considers the relations of care as more primitive and general than the one suggested by medicine. The need for care is born with man, together with human fragilities, and is in the vital origin and in the moral finality of medicine, where it gains a specificity. But the possibility of medical care is given by a chronologically and ontologically previous relation of care: the parental care. According to the author, all relations of care include two inseparable elements: one that is intentional, relational, addressed to someone, a willing to take care of someone (this is the central element in parental care); and another, that is to care for something, related to a specific knowledge and hability (the central element in medical care). But all acts of care necessarily include both the willing and the capacity to act.
Another important point about care is the usually apparent opposition between two ethics: to care about others, which is considered a humanitarian and generous feeling or attitude, and to care about oneself, which is related to an egocentered and selfish position. If we turn back to Ancient Greek and Roman wisdom we can learn about the care of the self as a precept of philosophical and moral life, which played an important role during one thousand years, from V a.C. to V d.C., before its modern elimination in favor of self-knowledge [3]. Epiméleia heautoû – ‘the care of the self’ was a way of living, of relating to others, of acting in the world, in order to achieve ataraxy (a state of tranquillity, free from emotional disturbance and anxiety) and autarky (the condition of self-sufficiency). It was the collection of self-transformations necessary to gain access to the truth, to blessedness, to completion, to spiritual peace and fulfillment. This pathway included full attention and daily care about nutrition, exercise, relationships, emotions, thoughts; and was developed along with someone else – a philosophical master, a relative or a friend. Galen said that man loves himself too much to be able to cure himself alone of his passions. In this process, the more a man works on his selfcare, the more he will be able to help others and the Society as a whole.
Towards a culture of care: the inspiration of palliative medicine and integrative care.
Turning back to the present situation of health services, we find a high prevalence of chronic diseases, and unsatisfied clients, who frequently abandon treatment or do not follow prescriptions, because they never received a self-caring education, or even a selfcare example from the professionals who attended them. Michael Balint used to say that the most important medication given by a doctor is his own presence. But what about the quality of the presence we can offer our patients? There are two areas in which we seem to be making progress on this requisite: palliative care and integrative care. In palliative medicine and care the focus is no more the anatomical lesion, the disease, but the human being who is trying to complete the history of his life, to set in order his emotions and beliefs before the end of the journey. He demands attention and care not only for his body, but for his soul. And the medical-patient relationship is the main instrument of healing during this period.
Integrative medicine was proposed in the nineties, originally in oncology services in USA, to fulfill the insufficiencies of the hegemonical medical care to attend the demands beyond the physical complaints. “Integrative Medicine and Health reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic and lifestyle approaches, healthcare professionals and disciplines to achieve optimal health and healing” [4]. Most practices that compose the Complementary and Alternative Medicine field and were included in integrative care are grounded on vitalism – a doctrine that ascribes the functions of a living organism to a vital principle distinct from chemical and physical forces. Therefore, as a consequence of their own rationality, these practices address the human being as a whole, including physical, mental, emotional and spiritual dimensions. Health professionals working in palliative and in integrative care are forced to convoke their body and soul, mind and heart, knowledge and willingness to care for their patients, and they work hard in developing the quality of their presence
Quality of Presence: Selfcare, Empathy and Trust
The quality of presence is not a discipline in the program of medical graduation and post-graduation courses. It is the result of everyday learning, from and with patients, their relatives and our colleagues. We identify three elements that seem to play an important role in the development of the quality of presence: selfcare, empathy and trust. It is very difficult to help somebody to take care of himself, to care for all aspects of life, if the health professional is not working on his own selfcare. The example is stronger than any or many words. Besides, we work better when we are happier and healthier. Many services already began to take care of their employees, and healing the healers is a main goal in several groups of health workers.
A second element is empathy, which should be distinguished from sympathy. We usually feel sympathy for persons of like tastes and opinions; it implies in harmony or agreement in feeling. Quite differently, empathy is defined as the intellectual identification with or vicarious experience of the feelings, thoughts, or attitudes of another. We’ll feel empathy with any person if we can see that all beings have much in common and are systemically joined – being human necessarily implies needs and potentials, and the suffering or cure of each one will impact the whole system. A relationship based on empathy will include respect and tolerance to all kinds of differences, in feelings and opinions. The professional will recognize the diseased parts of his own self, as well as the healthy and wise parts in his patient. He will realize that someday he might be in a similar condition to that in which his patient is living now, with an equal amount of pain and suffering and hope and love. Empathy is a sort of complicity with every other human being in the art and work of developing our humanity
We want to point out yet a third element: trust. We need to trust each other being as a subject capable of dealing with life and death, as the subject of his own life and of his health-andhealing process. Recognition of the potency in each being is the ground where may emerge self-confidence, courage, hope, selfsatisfaction, love for oneself, and selfcare. Inside this triangle, draw by selfcare, empathy and trust, our work of caring for and taking care of others will be tied to our own wellbeing, inside an ethics of co-responsibility and emancipation.
Final Considerations
Care is an essential dimension of life, and requires, at the same time, competence and willingness. The quality of presence is a main instrument in every area and therapeutic approach in health care. Should we dedicate more attention to selfcare, empathy and trust, and our patients would be far more satisfied. And we would probably be happier and healthier.
References
- Heidegger M (2008) Being and Time. Harper Perennial Modern Classics.
- Worms F (2006) Les deux concepts du soin. Vie, médecine, relations morales. Esprit: comprendre le monde qui vient.
- Foucault M (2005) The Hermeneutics of the Subject; lectures at the College de France 1981-1982. New York: Palgrave Macmillan.
- https://imconsortium.org/about/introduction/