The Case of Treatment and Decision-Making and Nonadherence

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The Case of Treatment Decision-Making and Nonadherence

Mindfulness: A Partial Response to Burnout

Anyone who works in a healthcare related field is aware of the current (and growing) issue of professional burnout, which can be manifested as high levels of emotional exhaustion, diminished sense of personal accomplishment, and a cynical attitude (Maslach & Leiter, 2016). Burnout can have a detrimental effect on the providers who are experiencing these symptoms, including suicide and depression (Kuhn & Flanagan, 2017). It can also have a negative impact on the patients we serve. A study by Salyers et al. (2016) found a connection between provider burnout and patient safety stating, “burnout may contribute in part to real-world outcomes for patients, putting them at higher risk of an error or adverse event” (p. 480).

While healthcare burnout and its link to quality and safety is an extremely important discussion, the topic here will instead focus on what can we do to prevent burnout. One of the ways to do so before it becomes an issue is mindfulness.

Benefits and Limits

But what is mindfulness? Modern mindfulness practices trace their origins to Buddhism and the practice of sati. While there is no exact translation, sati is the practice of being aware of the present, understanding our place within time, and accepting that place and time. To put it in other words, “Mindfulness is the basic human ability to be fully present, aware of where we are and what we’re doing, and not overly reactive or overwhelmed by what’s going on around us” (https://www.mindful.org/what-is-mindfulness/).

The embrace of mindfulness practices has been shown to have beneficial effects for providers and, through them, their patients. In a 2012 published study, Goodman and Schorling showed the benefits of a mindfulness program. Before the study, participants took an Emotional Exhaustion and Depersonalization test to understand their baseline which showed that “the level of distress was high among the participants…the mental health scores for both groups were below the average for the U.S. population” (p. 125). After an eight-week mindfulness class “…significant improvements in a number of measures including decreased burnout that last for a total of 15 months” were found (p. 125).

These results are similar to another study done by Cohen-Katz et al. (2005) on nurses’ stress. The study showed “significant improvement on the MAAS (Mindfulness Attention Awareness Scale)” (p. 33). Still, the authors do not see mindfulness as the end solution, further stating that “practicing mindfulness techniques not only give profound benefit to the practitioner, but it also requires tremendous discipline and persistence” (p. 33).

Incorporating Mindfulness

So how can we embrace these qualities and help improve ourselves and our patients? In one of many lectures, Dr. Barry Kerzin of the Altruism in Medicine Institute talks about the benefits of Emotional Hygiene (https://www.youtube.com/watch?v=SujrWXX3lAU). He argues that to benefit ourselves we need to recognize the negative emotions we are experiencing and “cleanse them.” This can be done with mindfulness practices, by remaining, focusing on promoting beneficence towards the current patient, and not allowing a history of negative emotion to impact the current situation.

Incorporating mindfulness is not the solution to burnout or moral and emotional distress but has been shown to offer benefits. As Cohen-Katz et al. state, addressing burnout needs to be a multifaceted strategy and that “researchers have noted that burnout is largely related to factors within the organization, rather than the individual, that exacerbate stressful situations” (Cohen-Katz, p. 33).

Mindfulness can help providers handle these stressful situations, but it should not be seen as sufficient or the only solution. The mental and emotional health of healthcare providers is not the sole responsibility of the providers themselves but rather the collective concerns of all involved in healthcare. Until stressful situations are meaningfully address by all, mindfulness can at least offer a partial positive response to professional burnout.

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Case Study

Patient is a 30-year-old female, presenting with multiple co-morbidities including HIV, COPD and cardiac complications. After several weeks in the ICU, patient’s condition continued to not improve. Due to, in all likelihood, the patient’s nonadherence to medical care over the years and “reckless behavior,” there is little expectation for a full recovery. The attending physician was heard saying, “I’ve seen this patient a million times. Another one who does not care about herself. Why should we have to care about her? Care more about her than she cares for herself.” The physicians then put in a recommendation to not place a trach and peg and change code status to “comfort measures only.” The nursing staff are concerned that the physician is “not giving this patient a chance.” An ethics consult was requested.

Ethical Musings

Mindfulness and Patient Decision Making: Past, Present and Future

Humans are gifted with an interesting perspective to understanding the universe and our place within it. Traditionally, there are three different periods of time: past, present and future. Our understanding about each of them is completely distinct. We exist in the present, we remember the past, and we will eventually be in the future. Our interactions with each one are different too.

We can remember the past (or as much as we are actually able to) as events that have already happened, document them in our brains, and recall them at will. We exist within the present. We have the ability to immediately cause change. Events are only experienced in the present. Even if you recall a tragedy or terrible event, while the event we remember happened in the past, it is in the present that we experience the pain again.

The future is also unique. Unlike the past and present, we do not know what the future holds, but we feel we can take steps to achieve a hopefully better one. This is our experience of time; the past flows into the present and future and only in that direction. We can know the past, we can change the future, but we can only live in the moment.

Cultural Differences

Culturally, we just accept this as truth and we do not really spend the time to think about it. How we express different times impacts how we understand it, and thus how we interact with it. In the Sicilian language, there is no future verb tense. Because of this, to the Italian ear, the Sicilian way of expressing future actions sounds uncultured. “Tomorrow I will write to you” in Italian is Domani scriverò, but in Sicilian it’s Dumani ti scrivu (Tomorrow I write you) (The First Romance Language). Without a dedicated future verb tense, the way Sicilian people interact with the future can be unique.

We think in language and the relationship between thought and language raises challenging questions. Wittgenstein addressed these challenges in writing to Bertrand Russell , “I don’t know what the constituents of a thought are, but I know that it must have such constituents which correspond to the words of Language” (Wittgenstein, p. 61). This connection between language, thought and time may seem the stuff only suited for ivory tower philosophers to contemplate, but it actually has real world implications.

Learn from the Past to Understand the Future

Each of these separate distinctions of time play an important role in healthcare. We need to know a patient’s past, to make better decisions in the present, so as to achieve a better future. We tend to think about death involving three- phases: dying, death and dead. Dying is the process (heavily involving the past for something cannot be a process with the passage of time), death is the present act of death, and dead is the eternal future state of death. The past, and therefore memories, are also a defining characteristics of each person. Who are we, our selves, if not the collection of past events. Think to yourself, if you lost all of your memories: Would you still be you?

Understanding this helps to better understand why patients make the decisions they do. Understanding their pasts and who they are as selves, can help understand their hopeful futures and goals of care.

Mindfulness is understanding that, as humans, we may experience and understand these different dimensions of time, but we can only exist in the present. Fully embracing that can be. But to not think about the past and to not worry about the future, — to only think about the present — is liberating.

This is where some of the benefits of mindfulness come from: to understand our place in the universe and how we exist within it. It’s not to argue that the past and future have no value; actually quite the opposite. Rather, it’s to understand their appropriate value. To use the past to learn from but not to dwell on the past. To hope for the future but not stress about it. We understand and experience three different states of time, but it is unhealthy and unproductive when we try to experience them all at the same time. When providers are mindful of the present, they are better able to provide better care; to both their patients and themselves.