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© 2003 American Society for Clinical Oncology
A "Good Death" Revisited in the Context of Doctor-Patient Relationships
Groote Schurr Hospital, University of Capetown, Cape Town, South Africa To the Editor: The article on the care of dying patients by Gazelle skillfully describes some of the ways in which the death can be made more peaceful.1 She notes the medical management of symptoms and the integration of the medical support services to improve the quality of life of patients. She also notes the need to help people live as well as possible until they die and alludes to doctors bearing witness to physical, emotional, and spiritual suffering. This may be interpreted, perhaps inadvertently, as reflecting a paradigm in which health care personnel undertake active management and the patient is a passive recipient of their care. The nature and importance of the doctor-patient relationship merits further elaboration in the care of dying patients. The ethical background, as well as the emotional and spiritual consequences of this relationship, is discussed below. As professionals, physicians have enjoyed considerable authority in the care of ill and dying patients because of their medical knowledge. This is recognized as a paternalistic model when the consequent doctor-patient relationship is based largely on patients’ trust and physicians’ conscience. More recently, society has increasingly wished to set limits on doctors’ authority in order that medical decisions might be more informed and determined by patients’ values and goals. For example, in patients with progressive cancer, it is the patient’s values that will direct a decision on continuing anticancer therapy when there is limited possible gain. There is, therefore, a shift toward shared decision making in health care. This may occur on the understandings of, for example, a "contract model." Key components of this model are patient autonomy coupled with professional duties and competence. This model, however, has been criticised as representing the interactions of strangers. A richer model is one based on a care ethic, which emphasizes the development of authentic human relationships between health care professionals and patients.2 It includes elements of the contract model but elaborates on the conditions for significant relationships. These conditions include openness, responsiveness, and fidelity. They also include a sense of mutual interest, although the goal is always the patient’s well being. Openness and responsiveness within a relationship involves appreciation of and response to patients’ individuality in terms of their perspectives, their values, and the contributions they have to make toward their health care. Fidelity touches on the justified expectations that are part of a relationship. It includes the anticipation that doctors will stand by them in difficult times. There is greater scope for the expression of, and a sympathetic response to, emotions within a relationship. Appropriate emotions are not a disruption of reason and are part of the integrated response to the outside world. They are particularly relevant in patients with life-threatening illnesses. Doctors can recognize and often reciprocate feelings of sadness or indeed cheerfulness. Patients are best helped to deal with anger through sympathetic understanding. Responding to emotions allows doctors to draw closer to their patients. Serious and progressive illness is a time when patients may confront and think deeply about illness and death and put them into a larger framework of spiritual issues. Spirituality is about moving beyond immediate physical realities and the biomedical engineering model of health care, where the focus is on the patient’s cells, organs, and reflexive emotional responses. Spirituality concerns deeper values and issues, such as meaning and purpose—be they from a religious or nonreligious viewpoint. It embraces a unitary perspective of life, which includes health and illness. It directs decisions where science alone is not sufficient, and assists when science has reached its limit in disease and symptom management. For many people, spirituality is closely linked with their sense of community, which includes the medical personnel with whom they have a relationship at this crucial time of their lives. Within a relationship, there are mutual opportunities to develop and grow. Both patients and doctors can learn about appreciating life, about equanimity, and about caring for others. In addition, some patients are able to show leadership by example. They create new possibilities and inspire those around them. It is a great privilege to care for patients with serious illnesses, whatever the outcome. The nature of the doctor-patient relationship is a central value in dying patients for both doctors and patients.
Originally published in Journal of Clinical Oncology, Vol 19, No 19 (October 1), 2001: 3999.
1. Gazelle G: A good death: Not just an abstract concept. J Clin Oncol 19:917–918, 2001 2. Benner P: A dialogue between virtue ethics and care ethics, in Thomasma DC (ed): The Influence of Edmund D. Pellegrino’s Philosophy of Medicine. Dordrecnt, the Netherlands, Kluwer Academic Publishers, 1997, pp 47–61
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Copyright © 2003 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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