Considering suffering and the person of the patient

In the last edition of Medicus Matters, we explored the idea of building a therapeutic doctor-patient relationship by using active listening to explore the patient’s illness experience and attending to how their life may be impacted. The idea is that by being ‘heard’, the patient will know that their doctor cares about them. Management decisions can then be mutually agreed upon and better understood, and we believe the risk of complaints (usually predicated on adverse outcomes) will be reduced.

Let us now take this discussion to a somewhat higher level than ‘Patient Care 101’.

Most doctors would agree that their core goal in patient care is to reduce suffering. This principle is independent of which branch of medicine you work in, and the idea of reducing suffering can be applied to individual patient care, family care, communities, and society more broadly. You might even go global! What needs to be defined however, is the nature of suffering itself, and that is more challenging than you might think.

Obviously, bodily pain is a form of suffering – we attend to fractured radius, appendicitis, various cancers, and so on, where the underlying pathology gives us a good indication of how an afflicted patient might suffer. But picture this: a young mother presents unable to sleep, not eating, tearful, and losing weight. Her baby is in a paediatric intensive care unit, septic, intubated, and on the verge of multi-organ failure. Where is the suffering? Obviously, the baby is sick, but so is the mother (and the father too). But what demonstrable pathology, what disease process, accounts for the way she feels? For us as doctors to care for her, we need a framework to understand her suffering and perhaps alleviate some of it.

We have palliative care physicians to thank for advancing our understanding of suffering, as they grappled with the idea of how to care for patients who were clearly dying, but whose suffering came from more than just their physical decay. To move to the answer: suffering happens when there is a threat to our sense of personhood. If we engage with our patients and explore – or at least let them explain to us – how their sense of personhood is threatened, we deepen the doctor-patient relationship and open ideas for helping that may have never occurred to us.

The tripartite body, mind, and spirit concept of personhood has its place but is too broad and too limited to be of much practical use. Persons have a body (much of our day-to-day work involves this), and threats to normal bodily function are not too difficult to identify. Persons also have personalities and character; they have a past that may shape how they are presenting today; they have family and a multitude of relationships that are deeply personal and intrinsic to how they see themselves; they have roles and responsibilities that can be threatened by their illness; persons are political and have agency in the world; they exist in various cultures with their values and belief systems; and in our view, of particular relevance to complaints, they have a perception of their own future. All these components of personhood can be threatened and result in suffering.

The young mother is suffering terribly because, at the very least, her relationship with her baby and the perceived future of her family are being threatened by her baby’s situation. If all we appreciate is that she has headaches and fatigue, and we prescribe for those symptoms without listening to her, or allowing her to explore her fears and concerns about those aspects of her personhood that are being threatened, then we risk completely missing the nature of her suffering and the opportunity to provide care. Missing these elements opens the gates for complaints, whereas exploring the components of personhood that might be threatened in any patient care situation reduces the risk of complaints and facilitates better care, which is our responsibility. It is not that difficult to do - give it a go!

Wayne Cunningham

General Practitioner