Suffering–At the Bedside of the Dying

SUMMARY

Care of people at the end of life is a challenge for the person with a life-limiting illness, their family and friends, and their professional carers. Clinicians, including pastoral care workers, nurses, doctors, and allied health professionals, find themselves at the bedside of the dying. At times, the professional's sense of self is challenged both by the suffering that they witness (physical, emotional, existential, social, sexual, or financial) and a sense of helplessness to relieve not only the patient's suffering but also that of the people to whom the dying person is close. What framework can help us to deal with the suffering that we cannot help but encounter? Ultimately people connecting in a real and meaningful way with other people is probably the only way that each of us can confront suffering and not have it destroy us. Creating an environment where people can begin to, or continue to connect with others at a level that is meaningful for all concerned is a pivotal starting point in dealing with suffering in any encounter with people at the bedside.     

Who should manage care? The case for patients

After establishing that it is essential that health care be rationed in some fashion, the paper examines the arguments for and against clinicians as gatekeepers. It first argues that bedside clinicians do not have the information needed to make allocation decisions. Then it claims that physicians at the bedside can be expected to make the wrong choice for two reasons: their commitment to the Hippocratic ethic forces them to pursue the patient's best interest (even when resources will produce only very marginal benefit and could do much more good elsewhere) and their values will lead them to calculate the net value of treatments incorrectly. Alternative decision makers are considered. It is argued that both groups of physicians and administrators will also make allocations incorrectly and that leaving the allocation decisions to patients themselves is the best approach. Mechanisms for fair and efficient rationing by patients at the societal and individual level are examined.     

Confessions of a bedside rationer: commentary on Hurst and Danis

Samia Hurst and Marion Danis provide a thoughtful framework for how to judge the morality of bedside rationing decisions. In this commentary, I applaud Hurst and Danis for advancing the level of debate about bedside rationing. But when I attempt to apply the framework to my own clinical practice, I conclude that the framework comes up short.     

Causality and the categorisation of objects and events

The “Tower of London” puzzle was adapted to tablet PCs to be used as a clinical bedside test. “Iso-problems”, a specific class of problems, require identical moves but ball colours are permuted. Thus difficulty is the same even if the appearance is different. We wanted to determine the impact of these as yet little-studied tasks and hypothesised that there may be a learning effect specific to them (the “iso-effect”). We interspersed a set of six iso-problems within one selection of 22 tasks and analysed problem solving by 81 healthy adults (mean age 41.6 years). Participants showed learning across iso-problems (less time, fewer moves, increasingly efficient solutions). This effect was distinct from general learning, as was obvious from comparison with a series of non-isomorphic tasks. However, participants seem not to be aware of solving such problems. This “iso-effect” may be related to implicit memory, a domain that so far has not been assessed using the Tower of London.     

Clinical ethics and the suffering Christian.

Contrary to the ecumenical spirit of our time, the differences among the Christian religions bring into question what one can say or do in common with fellow Christians. This issue, echoing the program of this journal, accentuates those differences, specifically when we focus on the Christian who is ill and suffering. At the bedside, it is the specifics of a religion, including not only its doctrines, but its informing and sustaining narratives, that must particularly be brought into play for the sake of the patient. Given this, our focus in this article regards what such a view implies for the clinician who is caring for a Christian patient whose religion he may or may not share, in general or in its specifics. Our basic conclusion is that the tendency for the clinician to act as both the patient's spiritual counselor, as well as his clinician, is generally neither prudent nor appropriate. Both hats should not be worn concurrently. This view is advanced not only because of concerns regarding patient vulnerability and the possible abuse of power, but also because the two roles may collide with or undermine each other.     

Early neuropsychological correlates of later clock drawing and clock copying abilities among school aged children.

Although widely used in empirical study and bedside neuropsychological evaluation of geriatric populations, there is little literature on clock copying and drawing among children. However, existing research suggests that clock drawing tests (CDTs) may be effective and efficient tools for assessing neurocognitive development in children. This paper reports data on clock drawing on demand (CDT-D) and clock drawing to copy (CDT-C) among a non-clinical sample of elementary school aged children and identifies predictive relationships between earlier measures of executive function, visuo-construction, and visual-motor coordination and CDT performance 3 years later. Similar to findings with adult samples, analyses revealed better performance on copying than on drawing. Longitudinal analyses indicate that general intelligence significantly predicted performance on both tasks. Visual-motor coordination only predicted performance on the drawing on demand subtest of the CDT.     

Hypersexuality in inpatient children and adolescents: recognition, differential diagnosis, and evaluation

We describe a 17-year-old girl with hypersexuality resulting from virilization, the latter a consequence of polycystic ovary syndrome, and we review the literature pertinent to hypersexuality in children and adults. Inappropriate sexual behavior (a common cause of disruption among children who are hospitalized for psychiatric disorders) may be caused either by hypersexuality or by simply ill-regulated behavior: a definition of hypersexuality is proposed that can be applied at the bedside (namely, sexual behaviors or fantasies that have abruptly increased in frequency by comparison with a previous baseline, are of sufficient excessiveness to disrupt expected or usual social, academic, or occupational functioning, or constitute a source of distress), so that this distinction can be made promptly, and we present a differential diagnosis for hypersexuality to direct its evaluation. Virilization does not seem to be a common cause of hypersexuality in children and adolescents, but it should not be overlooked when it does exist. The differential diagnosis of hypersexuality in adults, which we present for comparison, is much larger than it is in children.     

The clinical ethicist at the bedside

In this paper we attempt to show how the goal of resolving moral problems in a patient's care can best be achieved by working at the bedside. We present and discuss three cases to illustrate the art and science of clinical ethics consultation. The sine qua non of the clinical ethics consultant is that he or she goes to the patient's bedside to obtain specific clinical and ethical information. Unlike ethics committees, which often depend on secondhand information from a physician or nurse, clinical ethics consultants personally speak with and examine patients and review their laboratory data and medical records. The skills of the clinical ethics consultant include the ability to delineate and resolve ethical problems in a particular patient's case and to teach other health professionals to build their own frameworks for clinical ethical decision making. When the clinical situation requires it, clinical ethics consultants can and should assist primary physicians with case management.     

Effects of orientation on Rey complex figure performance

An experiment was performed that examined the impact of stimulus orientation on performance on the Rey complex figure. A total of 48 undergraduates (24 men, 24 women) were randomly assigned to one of four Rey figure orientation groups (0 degrees, 90 degrees, 180 degrees, and 270 degrees ). Participants followed standard procedures for the Rey figure, initially copying it in whatever orientation group they were assigned to. Next, all participants performed a 15-20 min lexical decision experiment, used as a filler task. Finally, and unbeknownest to them, participants were asked to recall as much of the figure as they could. As expected, results revealed a main effect of Task (F = 83.92, p < .01), in which copy performance was superior to recall performance. However, the main effect for orientation was not significant, nor did orientation interact with task (Fs < .68, ps > .57). The results are important from an applied setting, especially if testing conditions are less than optimal and a fixed stimulus position is not possible (e.g., testing at the bedside).     

CBL、PBL及Seminar结合的立体教学模式的应用和思考——临床医学八年制呼吸科床旁教学实践中的应用

临床医学八年制内科学床旁教学应用传统的教学模式及基于案例的学习（CBL）单一教学方法难以满足教学要求.将CBL与基于问题的学习（PBL）及研讨会（Seminar）结合的立体教学模式应用于呼吸科的床旁教学实践中,激发了学生学习的积极性、创新性,培养了学生良好的团队合作精神和临床思维模式,提高了学生们解决临床问题的能力,并能加深师生互动交流,达到教学相长的目的.     

THE ENCHANTED BEDSIDE

This paper is based on the authors' work offering psychological therapies to patients and their families in a specialist palliative care unit, pre‐ and post‐death. In addressing issues of family interaction around the bedside of the dying patient, the authors have noted a pattern of events that arise from strongly ambivalent relationships.

In particular, family adjustment to the declining health of the patient is acted out in a physical and emotional move around the bedside, with a ‘hierarchy of bereavement’ indicating the status of the relationship to the patient. Previously conflicted feelings towards the dying patient are replaced by an impermeable idealization, lasting throughout bereavement.

In trying to understand this process of idealization the authors have used an analytical frame, referring to Freud and Klein and their work on mourning. This leads on to an exploration of the implications for clinical practice within palliative care. An unshifting idealization can be problematic for many reasons. The reader is left with a discussion about how to work best with families whose initial protective defence can easily crystallize into a long‐term grief reaction.     

我国医学院校临床实习质量评价实施现状调查研究

对全国112所高等医学院校临床实习质量评价实施现状调查表明:我国临床实习质量评价方法单一,绝大多数学校采用床边考试和多选题加论述题的考试方法来评价临床实习质量.为此,应进一步开展临床实习质量综合评价的研究,尽快建立一套科学合理、行之有效的临床实习质量综合评价体系.     

From the Galleries to the Clinic: Applying Art Museum Lessons to Patient Care

Increasingly, medical educators integrate art-viewing into curricular interventions that teach clinical observation—often with local art museum educators. How can cross-disciplinary collaborators explicitly connect the skills learned in the art museum with those used at the bedside? One approach is for educators to align their pedagogical approach using similar teaching methods in the separate contexts of the galleries and the clinic. We describe two linked pedagogical exercises—Visual Thinking Strategies (VTS) in the museum galleries and observation at the bedside—from “Training the Eye: Improving the Art of Physical Diagnosis,” an elective museum-based course at Harvard Medical School. It is our opinion that while strategic interactions with the visual arts can improve skills, it is essential for students to apply them in a clinical context with faculty support—requiring educators across disciplines to learn from one another.     

Influence of Stimulus Salience and Attentional Demands on Visual Search Patterns in Hemispatial Neglect

Seventy-five left and right brain-damaged patients, with or without hemispatial neglect, and 40 age-matched control subjects were tested on cancellation tasks with two different visual textures modeled after Julesz (1981). In one condition (“preattentive”), target elements segregated easily from background elements and were perceived effortlessly. In the other (“attentive”), target elements did not segregate easily and could be detected only after prolonged focal scrutiny. Both controls and patients were more accurate and faster on the preattentive than attentive texture. However, only neglect patients were disproportionately impaired on the attentive texture, thus suggesting that unilateral neglect is exacerbated by the low visual salience of the stimuli and a higher engagement of focal attention. Thus, a simple bedside test may help to tell apart the level of visual information processing maximally impaired in neglect patients.     

Seven Vulnerabilities in the Pediatric Research Subject

Most recent thinking about thevulnerability of research subjects uses a``subpopulation' focus. So conceived, theproblem is to work out special standards forprisoners, pregnant women, the mentally ill,children, and similar groups. In contrast, an``analytical' approach would identifycharacteristics that are criteria forvulnerability. Using these criteria, one couldsupport a judgment that certain individuals arevulnerable and identify needed accommodationsif they are to serve as research subjects.Seven such characteristics can be evident inchildren: they commonly lack the capacity tomake mature decisions; they are subject to theauthority of others; they (and their parents)may be deferential in ways that can maskunderlying dissent; their rights and interestsmay be socially undervalued; they may haveacute medical conditions requiring immediatedecisions not consistent with informed consent;they may have serious medical conditions thatcannot be effectively treated; and they (andtheir parents) may lack important sociallydistributed goods. Each of thesevulnerabilities can call for special care inthe design and implementation of researchprotocols.     

What does a man do after he makes an error? an analysis of response programming

When people make errors during continuous tasks they temporarily pause and then slow down. One line of explanation has been that they monitor feedback to detect errors, that they may make incidental responses when errors occur (e.g. they may swear) and that they may pause to analyse their errors. In all these cases they may be assumed to act as single channel information processing systems of limited capacity, and to be unable to recognise any new signal until these processes have been completed.

Analysis of response after errors shows that this cannot be the case. Responses after errors are inaccurate, but are not slow when they require the subject to make the response which he should have made on the previous trial (i.e. to make an error correction response). Subjects thus must recognise new signals as soon as they occur. The present results require a new model of error detection and correction, and a model for response programming and priming.     

The promises and perils of pragmatism: commentary on Fins, Bacchetta, and Miller

Fins, Bacchetta, and Miller's clinical pragmatism has several appealing features: an emphasis on dialogue, a commitment to consensus, a focus on particular individuals rather than persons in general, and a strong interest in the process as well as the product of moral decision making. Nevertheless, for all its protests to the contrary, clinical pragmatism has a tendency to privilege medical facts over nonmedical values, to conflate appropriate medical decisions with right moral decisions, and to conceive problems at the bedside in terms of "getting" patients and families to "go along" with the treatment plans of clinicians. In sum, there is within clinical pragmatism the potential for physicians to take back some of the power they ceded to patients during the height of the patients' rights and autonomy movement. Provided that clinicians guard against the temptation to use clinical pragmatism manipulatively, however, the method promises, more than most other methods of moral problem solving, to help increasingly diverse individuals make good moral decisions about patients' care under conditions of enormous uncertainty.     

Patients’ Perceptions on Their Involvement in Medical Education: A Qualitative Pilot Study

Patients’ perception with regards to their use in medical teaching is an under-researched area in Pakistan. The objective of this qualitative, pilot study was to determine the perspectives of hospital admitted patients on their being used in the medical education of students in a private medical institution. An attempt to understand the dynamics of interactions between patients, students and doctors was also made and to see how this affected the doctor-patient relationship. A qualitative study with in-depth interviews was conducted in a private medical college of Islamabad, Pakistan with a total of 20 adult patients. The focus was on their experiences with bedside teaching. This pilot study reveals interesting findings about patient-physician interactions in Pakistan. Patients had a traditionally passive role in medical education putting more onuses on the doctor to impart knowledge to the medical students. Patients comforted themselves in the knowledge that they were following Allah’s command when they were involved in the teaching of medical students. The apparent altruism of Pakistani patients in this study was influenced mainly by religious reasons, following the commandments of Allah to help develop future healers for humanity. The culture evident in the medical college where this study was conducted is reflective of the social power ladders that pervade Pakistani society. The positions of doctors and medical teachers in Pakistani society are hardly challenged to debate. Little attention has been paid to the values that influence the cultural and social frameworks within which Pakistani medical teachers, medical students and the patients function.     

Filled pauses and gestures: It's not coincidence

Though filled pauses and gestures frequently accompany speech, their function is not well understood. We suggest that it may be helpful in furthering our knowledge of these phenomena to examine their relationship to each other. To this end, we carried out two studies examining whether they tend to occur together, or to occur at separate times. Both faculty colloquium speakers and undergraduate subjects used filled pauses less frequently when they were gesturing than when they were not gesturing. This effect held for 30 out of 31 subjects. We suggest that detailed theories may be premature, but speculate that gestures may be an indication that the speech production apparatus has completed its search for the next word, phrase or idea and is ready to continue.     

Looking forward to looking backward: the misprediction of regret

Decisions are powerfully affected by anticipated regret, and people anticipate feeling more regret when they lose by a narrow margin than when they lose by a wide margin. But research suggests that people are remarkably good at avoiding self-blame, and hence they may be better at avoiding regret than they realize. Four studies measured people's anticipations and experiences of regret and self-blame. In Study 1, students overestimated how much more regret they would feel when they "nearly won" than when they "clearly lost" a contest. In Studies 2, 3a, and 3b, subway riders overestimated how much more regret and self-blame they would feel if they "nearly caught" their trains than if they "clearly missed" their trains. These results suggest that people are less susceptible to regret than they imagine, and that decision makers who pay to avoid future regrets may be buying emotional insurance that they do not actually need.