Worlds of Connection: Applying an Interdisciplinary Relational Model of Care© to Communicating About End of Life

Susana Lauraine McCune

DEATH IS NOT THE ENEMY

Death is a human universal. Death is inclusive. Death is multicultural and multiracial. Death is not ageist or sexist. Death is the great equalizer. Death impacts everyone who is living, and does so during all phases of the life span. Why then is modern American society so resistant to discussing death and the truths of aging and medical care that bring us to death? Our current medical culture and health care system appear driven to use all available medical care to prevent, or at least postpone, all deaths in all situations and at all costs.

Advanced medical technologies can extend life almost indefinitely. Sulmasy (2002) commented that “today's health professions seem to have become superb at addressing the physical finitude of the human body. Previously lethal diseases have either become curable or have been transformed into the chronic” (p. 24). Sulmasy notes here that while medicine has advanced to the point of being able to cure many lethal diseases, one effect of such advances is the current high prevalence of chronic diseases. This means that while more people are living longer, experiences of disease and frailty that lead to physical and mental incapacity over an extended duration of the life span are now common patient experiences that require long-term planning. Even though advanced medical technology has been able to cure deadly diseases and postpone death, the prominence of chronic diseases and new choices about which technologies to use and when to use them requires longer-term attention. This requires all of us, including clinicians, to give more attention to the prospect of extended medical care over a longer period of life. This in turn requires that clinicians be able to address the needs of whole human persons, and not just give attention to producing physiological effects on parts of the finite body that are most visibly affected by disease. However, contemporary medicine, as Sulmasy stated, “still stands justly accused of having failed to address itself to the needs of whole human persons and of preferring to limit its attention to the finitude of human bodies” (p. 24).

Holistic treatment of patients can help counteract the body-bound, or strictly physiological, understanding of the patient that technology has encouraged. Sulmasy (2002) observed that “genuinely holistic health care must address the totality of the patient's relational existence” (p. 24). Total care of the patient must also account for the ways in which the patient exists in relation not only to his/her disease, but also to the myriad factors—not solely the physical, but also the psychosocial dynamics that structure the patient's life. Sulmasy goes on to say that “the fundamental task of medicine, nursing, and the other health care professions is to minister to the suffering occasioned by the necessary physical finitude of human persons, in their living and in their dying” (p. 24). Toward this end, Sulmasy advocates a more comprehensive model of care that accounts for patients in the “fullest possible understanding of their wholeness—as persons grappling with their ultimate finitude” (p. 24).

A person's quest for psychological and existential meaning in the face of finitude continues across the life span (Reker & Chamberlain, 2000). The challenge for clinicians then is to recognize that companioning—accompanying—a patient as he or she conceptualizes and develops an advance care plan—a plan for dying and death—is as important as companioning a patient in developing a plan of care for curing disease—a plan for living.

Toward these ends, this chapter presents the Interdisciplinary Relational Model of Care© (IRMOC) as a theoretical framework that aspires to support clinicians' ability to engage with patients and their loved ones about advance care planning (ACP) for end-of-life (EOL) care and, in so doing, improve the quality and increase the frequency of communication about ACP. The tasks of this chapter are to bring together theoretical concepts and clinical skills that have until now been regarded and employed disparately. It will demonstrate how, when applied together, these concepts and skills can help clinicians feel more comfortable and confident conducting, and thus better facilitate, more frequent communication about ACP. The chapter begins with a discussion of the historical impact that the presuppositions of objectivity, paternalism, and autonomy have had on patient–clinician models of care in which ACP takes place. Next, the chapter considers the ways in which these presuppositions perpetuate dynamics that relational psychology understands as counterand cotransference (Orange, 1995, 2006). It will present emergent understanding from contemporary relational psychological theory that emphasizes compassion as a fundamental element in the patient–clinician relationship (Orange, 2006). This is followed by overviews of reflective practice and therapeutic communication skills that can help clinicians facilitate communication about ACP. The chapter concludes with a summary and a case study demonstrating the need for the IRMOC and ACP.

 
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