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Complex questions: thinking about compassionate care

For Dr Anne O’Callaghan it started 10 or 15 years ago when complications occurred after her cancer surgery.

“I couldn't get anybody to hear that I was worried about my paralysed legs and my pain,” she tells me. "And I think I was labelled as a difficult healthcare professional."

The compassion was lacking. But it's a new grad nurse who sticks out for O’Callaghan when she thinks back to that time. She doesn’t remember exactly what that nurse did, it was just the small acts of kindness that has transformed the memory of suffering.

It often takes a personal experience to shape your outlook on life and work. O’Callaghan is a palliative medicine specialist at Auckland Hospital and teaches at the University of Auckland, and time after time she has witnessed a lack of compassion for patients in her peers.

“Compassion is a complex concept,” she says.

The seemingly simple concepts of sympathy, empathy and compassion are in fact different things.

“Sympathy's often seen as a distancing kind of thing, where the person who's giving the sympathy is not actually standing very close alongside the person who's suffering… sometimes it's seen as unhelpful by the person who's experiencing it."

Empathy, she says, involves walking in someone else’s shoes and more vulnerability on the doctor or nurse's part.

Whereas compassion, albeit involving empathy, is more of a will or desire to act to relive someone’s suffering, and like that grad nurse from her past, often involves those small acts of kindness that are above and beyond the job.

Another case, another number

Putting yourself in the shoes of a doctor or a nurse, it would be easy to think of patients as cases. So many people come through the doors every day, and in terms of self-preservation, being emotionally detached could work for some.

“Historically, doctors have been trained to be dispassionate as opposed to compassionate. To have put feelings to one side and look at facts and the objective.

“So that is changing in medical schools. Issues of self-awareness, affection, emotions and compassion are now talked about and part of the discourse. So, that's an encouraging change."

O’Callaghan looks at it from a neuroscience perspective. From brain imaging, scientists have found that different parts of the brain are activated when we experience these things.

“There’s something about empathy that can switch on bits of the brain associated with aversion and negative states, whereas compassion switches on bits of the brain associated with reward and positive states.

“So, that does fit with the idea that people can get overwhelmed, [especially if they] sit day after day hearing really difficult stories and have no means to alleviate that suffering,” she says.

When I ask her when the phrase compassionate fatigue comes into play, she replies that empathic distress is a more accurate term. The care giver becomes so involved in a patient's suffering and it becomes so unhealthy that they shut down or withdraw.

So how do we help the health professionals to better help the patients?

Philosophical thinking

"How do we fix this system and flourish as human beings?" O’Callaghan wonders aloud, a question more reminiscent of Aristotle than a doctor. “And how can we have environments in which everyone can flourish and heal to whatever extent they're able to?"

In the next breath we are talking about Zen Buddhism.

“There's a social anthropologist called Joan Halifax, who's a Zen Buddhist and works in the Upaya Zen Centre in Santa Fe.

“She's done work in Nepal, and she has also worked with the Dalai Lama and with neuroscientists, and she's tried to bring together all these different facets to look really deeply at what makes compassion, and what can help us be more compassionate.

“And she's got a lovely little model called the G.R.A.C.E Model, which is a way that any individual could quite quickly help themselves to get into a compassionate state within our person."

The G.R.A.C.E acronym stands for Gathering attention, Recalling intention, Attuning to self/other, Considering, Engaging.

It is all about gathering your thoughts before a clinical encounter and remembering why you are where you are.

Communication is another big part of compassion. O’Callaghan teaches communication skills workshops and there are often very simple things clinicians can do to improve.

“Some of those skills are just moving forward, close to the patient, to show that you're present and saying what you need to say that's difficult for the person to hear before waiting and leaving silence. People need time to digest what's being told to them and people feel cared for and held when you give them a moment to collect their thoughts,” she says.

“They’re basically skills that help you to understand what's happening to the other person, help you recognise and respond to their emotions.

“All of us have experiences in which we've been with people where it's not possible to fix the pain. And by being there, and staying there, and holding the space, and not running away, and bearing it, we do something. It's not fixing, but it's something.”

All of these, O’Callaghan says, are ways in which clinicians can switch from the critical, scientific world to a compassionate world. It is about being aware of the difference that clinicians can make to a patient’s life.

Culture change

Concentrating on the individual health worker is often problematic and ignores systemic issues, and the so-called compassion fatigue is often more to do with the exhaustion that comes with the job.

When I put it to O’Callaghan that perhaps not all people have the natural capacity to be truly compassionate, she unpacks the last piece of the compassionate care puzzle – the culture of a workplace.

“I think we've all got this within us,” she says. “I think most people want to and do act from a place of kindness and generosity. And things happen around them that drum it out of them.

“So, for example, take a new grad nurse who is upset: a patient they've looked after has died and nobody talks about it, or somebody makes a negative comment about her reaction. What message does that give about how I, as a young health professional, should act in this sort organisation,” she says.

O’Callaghan says the literature shows us that teams that place emphasis on creativity and innovation instead of meeting targets and KPIs thrive, and going back to philosophy, teams that focus on wellbeing have better patient outcomes.

“We know medical outcomes improve when their care is compassionate, when they're communicated with well and effectively. Then their actual medical outcome improves and of course they feel better about the whole experience when satisfaction goes up and complaints go down."

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