The improvement of human relationships has always been a central issue in any area of personal relationships.
Carl G. Jung was a Swiss psychiatrist and psychotherapist who founded analytical psychology. It is his phrase: “Know all theories, master all techniques, but when touching a human soul, be just another human soul”.
In order to continue stimulating qualified debate and critical reflection, I propose some aspects to be analyzed. Uniting ethical behavior, technical knowledge, compassion and empathy are fundamental in the doctor-patient relationship.
This relationship involves ethical, philosophical, behavioral and even economic issues. Aspects of an economic nature, because it has already been used as an argument for inappropriate behavior the wear and tear arising from countless jobs necessary for survival or the low investment of the administration in the formatting and adequacy of the work environment.
Although all these arguments have some basis, they become fragile in the face of the need to overcome that is imposed, since a distant relationship with a patient weakened by the disease is unacceptable.
I learned many things at the Faculty of Medicine, but dealing with emotional fragility in the face of aggression that is a serious illness was not one of them. You learn in life.
Contrary to logic, the intensive care environment seems to contribute to a technical and less empathic behavior. This is without considering the pandemic, a moment that obviously isolated patients more from their families and they were attended by masked beings, which made identification difficult and, of course, the relationship.
Aside from the pandemic, I have already tried to enumerate several explanations for such behavior, but I will not do it again because no argument was able to justify this inexplicable fact alone.
Such is the relevance of the topic that in 2003 the Ministry of Health undertook to create a program with the objective of strengthening the bond between doctors and patients. This program called the National Humanization Program (PNH) tries to change the concept based only on voluntarism, welfarism and paternalism, and which is based on the ideal figure of the “good human”.
For the formulators of the PNH, humanization cannot be restricted to “humanitarian actions” and is not performed by human beings imbued with a “superhuman goodness” in the performance of “ideal services”. Thus, they proposed a reorganization of health work processes, with changes in the social relationships that involve workers and managers in their daily experience of organizing and conducting services. They also proposed changes in the ways of producing and providing services to the population.
In short, the idea was to change the way of managing and caring. It also stimulated communication between managers, workers and users to reduce dehumanized attitudes and enable joint work between them.
Perfect in theory. Had to match the actors.
Human relations are not improved by normative acts. Without investment in qualification, infrastructure, working conditions, training, a kind of logic that guides action, a new care model cannot be built.
But let’s go back to intensive care, which is our central theme. These units emerged in the 1970s with the objective of intensively caring for physical disorders generated by the disease or by highly complex surgeries.
There was a need to concentrate material and human resources and to improve the care of critically ill patients and those in critical, but still recoverable, patients. Also the need for medical assistance, a continuous multidisciplinary team with constant observation, centralized in a specialized nucleus.
However, at no time did he ask himself if there was an emotional structure to face such aggression and isolation. The emotional fragility installed by the disease and fear of death was aggravated by an environment without windows, clocks, contact with family members, without dental prostheses, glasses, clothes and the lack of communication; but this was not taken into account. In our view through the distorted optics of arrogance, lives are saved; then everything is justified.
Then, delirium appears in most of these patients, and this was considered for a long time an irrelevant issue, considering the increase in mortality of these patients, not to mention the worsening of suffering.
No wonder these units were and still are considered by a large part of society as places of death and suffering.
As if there were at the entrance of these units the same inscription that Dante and Virgilio, in the book “The Divine Comedy”, found on the door of hell: “lasciate ogni speranza, voi ch’entrate”, that is, “leave your hopes on the side of out, you who enter hell”.
Intensive care is a place of life. Patients who are hopelessly dying must remain with their families. This perception needs to be worked on in society. A resumption of this environment was necessary, not only changing the physical structure and communication with the outside through windows, clocks, televisions, but solving the dilemma of the security-privacy binomial.
The need and importance of constant team training was perceived.
Training human beings to be human? That’s right. Strange, but humanizing is a skill and requires constant training. It is necessary to recover the concern with the need, that is, in the last analysis, it is necessary to put oneself in the place. Practice every day enter the room and say: “My name is…, my job here is…, and I’ll take care of you for the next few hours and if you need me I’ll be here”.
This is turning off automation. Without it, actions are based exclusively on performing tasks.
Unfortunately, humanizing cannot be a set of pre-established norms and applied indiscriminately. Therefore, it is not possible to create a standard speech, fake a smile or a behavior. It takes attitude, developing solidary bonds, a posture, a feeling.
It is to understand fears, uncertainties and anxieties. It is still valuing all the elements involved in care, or ultimately developing affective respect for the other.
According to Jaime Betts, when he considers what is human and what it means to humanize (Portal Humaniza, 2003. Available at: www.portalhumaniza), “the things of the world only become human when they go through dialogue with others”, or that is, give voice to pain.
Unfortunately, the attitude of the doctor or the care team is often the avoidance, transferring this important moment, which is part of caring, to the “caregivers of the soul” who are the psychologists.
Another obstacle in this relationship within intensive care, as strange as it may seem, was the increase in technology.
Computer visits, analysis of imaging exams to the detriment of physical examination, contact and conversation, seem to be trends nowadays, due to an absolute inadequate analysis of priorities. Thus, there are sad reports of patients who say they feel extensions of machines and devices. People want to serve themselves, but not depend on technology.
The hostile environment of increasingly sophisticated intensive therapies makes them impersonal and inevitably depersonalizing. Thus, they do not only harm the patients hospitalized there, but the entire multiprofessional team that deals with family members at the limit of emotional control. These are patients who demand extreme vigilance (even so, their privacy must be protected) and with daily situations of extreme urgency, suffering and even death.
It is then up to the coordination of the ICU and the hospital administration to take care of this group (there, the notorious care for those who care), with more flexible schedules, better remuneration and, above all, with the formatting of a healthy work environment.
There is a consensus among multiprofessional teams that overwork, emotional stress of those who deal with life at its limit and inadequate remuneration are stressors that, no matter how much we fight against, distort our evaluations and hinder our relationships.
The struggle for survival has made us more skeptical and dangerously quick in our approaches to patients and families. Thus, we forget on a daily basis that doctors or not, nurses or not, we are all the same and we are going to get sick on this journey and die inexorably needing medical or simply fraternal and human help, if it is not the same thing.
Understanding the dimension of the human being not only as a biological being, but as a psychosocial being who has emotions, feelings and modesty is a fundamental part of this process. It is only then that the use of prostheses and orthotics (which in most cases is possible, instead of creating a single rule), the patient’s sleep (which is invariably disrespected) and especially the presence of the family .
They understand that despite getting sick together with the patient, the family is a fundamental part of their recovery.
The family member must always be present and, even so, frequent explanatory meetings instead of generic bulletins that do not inform anything and bring more stress and anguish, are essential. In addition to calming them down, information is a powerful ally against the only enemy that presents itself, which is the disease.
This contact, however, should not be formal, bureaucratic and depersonalized. Unfortunately, the misperception that the less information given, the better is not uncommon.
Although the meeting with family members is never neutral, because we always carry with us values, attitudes, prejudices, in short, our system of cultural meanings, it is always welcome because, in addition to having the right to correct information, sharing feelings and emotions is part of noble of the profession.
What is strange is that it is still necessary to reflect on the fact that despite this topic being exhaustively discussed, the violation of rights and dignity in these units is still flagrant.
Patients surrender their lives to strangers whose functions they are unaware of, and to routines totally disconnected from their habits. Thus, they become just another patient, a bed number, a pathology, being asked to discard their identity.
The phrases of Scotsman Dunbar William (1465 – 1530), “The fear of death disturbs me” (the idea of death scares me to death) and the Englishman Charles Chaplin, (1889 – 1977) “life should begin with death to get rid of it soon”, demonstrate the fear associated with the idea of dying. Surely the fear of death created religion and encouraged medicine.
Being hospitalized in an ICU leads us inexorably to the thought of death, justifying the fear and insecurity in these units.
Is it necessary to remind health professionals that these units will be temporary or final addresses for almost all of us? Do we lack this perception? Do we need more reflections on the topic?
These questions, whether answered or not, must permeate our work environment and our minds, with the aim of improving our positioning, values and attitudes, whether due to the main motivation, which is respect and compassion for others, or because humanized care is always found and will find support in society, since it is just.
Obviously, there is no intention here to establish a model of behavior for health professionals, but what is proposed are reflections, not from an academic point of view, but from a humanitarian point of view. Such ponderings, although painful, expand our minds, our freedom and make us all, doctors or not, fuller human beings.
The indisputable fact is that human relationships are sick, medicine is in shambles, not for lack of love or time, as these are symptoms and not causes, and no matter how many painkillers you take, you won’t find relief from your magnificent gifts and will end up destroying yourself. if not subject to a postural review.