Every day brings new advances leading to countless “medical miracles.” Historically, these were seen as an act of God. Today, technology delivers “miracles” on a daily basis.
As practitioners, competence increases with continuing education, improved technology, and innovative treatment options. Medicine has progressed far beyond the “rational medicine” of Hippocrates. The personal relationship between the patient and the clinician has evolved. The impersonal third party, technology, now dominates.
Historically, medical care was provided by members of the family and community. There was no differentiation of physical, mental, and spiritual care. As knowledge and learning expanded through universities, there was a philosophical shift in caregiving. By the 17th century, Rene Descarte’s Reductionist Theory promoted the separation of care of body and soul. He also introduced the third component, the mind, as an additional entity of the whole person (Lewis, 2007). Reductionism, the study of the body, mind, and spirit as distinct disciplines, resulted in the isolation of care seen today.
The advent of Cartesian philosophy signaled a change in the caregivers’ approach to the patient disease process. Opposed to the previous concept of a person in need of care, solace, and salvation in their final hours, the patient became an object of study. As our knowledge base advanced, experts in medical, mental, or spiritual care concentrated exclusively on their focus of study.
How clinicians perceive relationships with patients originated from End-of-Life care and the hospice movement. Addressing the physical suffering of the dying patient is inadequate. Providing an integrated approach to care for patient and family members’ mental, physical, and spiritual suffering results in healing. Originally limited to caring for the dying, the consequences of change are far-reaching. How clinicians communicate impacts every patient, not just the acutely ill or dying.
Despite advances, patient and family satisfaction in care has diminished (Lewis, 2007). This inverse relationship has taken generations to develop and decades to recognize. Unless patients are viewed as much more than diagnoses and/or treatment protocols, the whole patient is not cared for. Although attempts have been made to improve patient communication and satisfaction, education on this topic is limited to a chapter in a textbook or a class under the heading of mental health or ethics (Berg et al., 2013). The esoteric classroom discussion does not integrate easily into clinical practice. As a result, quality of care languishes. Clinicians become frustrated and burned out.
Relational Care creates more than a partnership. It is collaboration. Its value lies in establishing and maintaining communication among patient, family, and clinician. “No man is an island” is more than a quote from John Donne. It describes the necessity of seeing each patient as a person in relationship with the clinician, their disease, and their world. Practitioners are trained to look at specifics of the disease process – the pathophysiology. Relational Care techniques determine causation of the patient’s symptoms as well as the impact of the disease.
Two patients with the same dataset illustrate how Relational Care works. A 20-year-old white male presents with a 4-day history of cough, fever, and productive sputum. In Relational Care, the curious provider engages the patient in conversation. He works a 40-hour week, tending bar on the weekends to pay for graduate school, which he attends during the day. To stay awake and functional on an average of 4 hours of sleep a night, the patient has resorted to multiple energy drinks. A different perspective emerges which may or may not require more than medical intervention.
The same clinical presentation in a 20-year-old female may yield a different relational story. In conversation, she reveals she has dropped out of college. She works as a waitress to support her increasing methamphetamine habit. Her family has thrown her out of the house, and she has been forced to move in with her boyfriend. After talking for a few minutes, the patient also admits that she has had numerous sexual contacts while under the influence. She has lost substantial weight in the past 3 months.
With Relational Care, the patient, as a person with different values and social factors in place, adds to the simple pathophysiology of the presentation. Both cases present with the same symptoms – a case of pneumonia. Without knowledge of their lifestyles, standard evidence-based treatment would be prescribed. Relational Care reveals a more accurate “picture” of each patient. Their family and social environment suggest targeted treatment options and control of risk factors. Discovery is made during a relational conversation, not during a standard clinical evaluation.
The definition of health is complete physical, mental, and spiritual well-being (Lewis, 2007). This definition, authored by the World Health Organization, recognizes three integral parts of Personhood – Body, Mind, and Spirit. Personhood is determined by the integration of these three elements. In addition to this holistic relationship, the Healthcare Collaboration comprises the Patient, Family, and Clinician. Just as Body, Mind, and Spirit impact and influence each other, so does the relationship among Patient, Family, and Clinician. This use of Systems Theory expands healthcare.
Ignoring any element of the person or the healthcare relationship may cause suffering. Imbalance is created, even in an otherwise physically healthy person. As a practitioner, our avenues for healing are greatly increased when we pay attention to the relationships that are present in the physical, intellectual/emotional, and spiritual elements. Relational Care offers healing potential that moves beyond technology. As opposed to treating pathophysiology alone, awareness of the whole person in patient care expands our options and increases effectiveness in healing.
Relational Care does not take the place of understanding bioethics. Nor does it consist of new mental health interventions. Relational Care is a way of seeing the Patient through different lenses. It integrates the whole person into the disease process that Clinicians are trained identify and treat. Relational Care recognizes the value and effectiveness in addressing all aspects of relationships among Patient, Family, and Clinicians. The purpose of this text is to educate Clinicians on the possibilities of integrated Relational Care. Additionally, it provides self-protection and self-care concepts to remain effective and healthy.
Relational Care is personal. It changes how we communicate with our own Families, how we process disease and death, and how we care for ourselves and each other. It becomes part of what we are. It makes us better human beings and practitioners. Envisioning the Patient and the Clinician–Patient relationship adds depth to care and improves Patient satisfaction and compliance.
In 1996, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a policy requiring hospitals to provide pastoral counseling. In 1998, the Association of American Medical Colleges responded with the Medical School Objectives Project where coursework was required connecting spirituality and health (Puchalski, 2006). In 2004, JCAHO published a Spiritual Assessment Question guide (Appendix B.1). This series of suggested questions was recommended as an additional assessment tool.
Patients have significant concerns and questions regarding their spirituality and terminal condition. Despite that, less than 20% were able to discuss these issues with their providers (Mahler et al., 2010). Conversations, in relationship, should not be limited to Patient and physician. Family, other caregivers, and other Clinicians need to be included. The willingness to begin these conversations and recognizing appropriate timing are critical skills. Patients expect Clinicians to initiate these conversations.
Establishing a relationship requires time to develop and evolve. Patients want their values and needs appreciated and included in their care plan (Ellis & Campbell, 2004). Families want help in knowing how to care for their loved ones. Fears and personal needs require acknowledgment and support (Nelson, 2005).
Working with chronically and critically ill Patients is physically, mentally, and spiritually exhausting. Maintaining a healthy balance is vital. Relational Care offers resources and tools to prevent compassion fatigue and burnout.
Case studies have been included and appear in italicized text boxes. Some of the cases have no clear resolution. Some seem miraculous. These cases were chosen not to demonstrate a standard protocol or “sure fire fix.” They demonstrate how openness to Patient and Family concerns and awareness of outside influences impact care and decision-making. There is no standardized protocol that, once learned, can be employed in every situation. Relational Care is a personal relationship in caregiving encompassing all members of the Healthcare Collaboration.
Questions for Reflection
- Consider your typical Patient/Clinician interaction. What part does Family play in the Patient’s decisions regarding care?
- Electronic Medical Records improve the accuracy and efficiency of medical documentation. How have they influenced your Patient/Clinician relationship?
References
- Berg, G., Whitney, M., Wentlin, C., Hervey, A., & Nyberg, S. (2013). Physician assistant program education on spirituality and religion in patient encounters. Journal of Physician Assistant Education, 24(2), 24–27. https://doi.org/10/1097/01367895-201324020-00006
- Ellis, M., & Campbell, J. (2004). Patients’ views about discussing spiritual issues with primary care physicians. Southern Medical Journal, 97(12), 1158–1164. https://doi.org/10.1097/01.DMJ.0000146486.69217.EE
- Lewis, M. (2007). Medicine and care of the dying (p. 34). Oxford University Press.
- Mahler, D., Selecky, P., Harrod, C., Hansen-Flaschen, J., O’Donnell, D., & Waller, A. (2010). American College of Chest Physicians consensus statement on the management of dyspnea in patients with advanced lung or heart disease. Chest Journal, 137(3), 674–691. https://doi.org/10.1378/chest.09-1543
- Nelson, R. (2005). The compassionate clinician: Attending to the spiritual needs of self and others. Critical Care Medicine, 33(12), 2841–2842.
- Puchalski, C. (2006). A time for listening and caring (pp. 22–25). Oxford University Press.
