Tag Archives: Ethics

Thoughts on an abused child

child-abuse1interburns-child

ChildAbusedCrying

I have had the amazing opportunity to work at Red Cross Children’s hospital. I’ve learnt some amazing things on child care, but also been so shocked that child abuse seems so common. So often I’ve seen a patient who is neglected, physically or emotionally abused and it breaks my heart.

Paediatrics is something I’m very passionate about, and I’ve been thinking of writing a poem related to child abuse and this ethics course has given me the opportunity to finally do so. The material I read through/used is attached below. I have used one my personal experiences I had with one of my patients.

Thoughts on child abuse:

There is a girl of just 8 years
with tear stains in her eyes
From the shame she can’t hide.
She says, “why doesn’t my mom love me?”
She says, “it’s all my fault”
I try to comfort her,
she whispers to my ear that she wishes I were her mom.
I suspect child abuse,
how I wish I didn’t.
I distract her by playing games;
Games to improve the way her body moves.
Is there more I could do?
I feel helpless sending this girl home
just to be abused again.
I have no proof to give,
If I did I could report it.
Nothing to offer but physical therapy
and the occasional emotional support.

I’m crippled by the fear
that I’ve messed up too badly.
How can my mom love me like this?
My left arm and leg are not working
My body no longer listens to me,
it just sits there, lifeless.
They told me I had a stroke
but why can’t I move?
How can I ever please her again?
I can’t even walk.
I can’t play with my brother.
She doesn’t love me
and it’s all my fault.
I wish this young lady could be my mom
She is the only one who visits me in hospital.
She understands.
She helps me.
I’m scared of the day I have to go home.
My mom hurts me but I won’t ever tell on her.
She would only hurt me more.

I love her
I don’t know how to show her.
I never wanted children
but it was forced upon me,
one dreadful day.
He refused to wear protection.
Why I go back to him every time
I’ll never understand.
I’m afraid I’ll shatter her innocence.
Life is tough,
I do not have a job.
I have three hungry mouths to feed.
The only way to earn
is by selling myself on the street.
Sometimes she makes me mad,
she always wants to play.
I hit her,
sometimes so hard she bleeds.
The word “sorry” never seems to escape my lips.
I speak words of hate
Because I had a bad day.
Nobody understands the pain I go through
just to give her some food.
What if she gets taken away?
Away because of me.
Maybe then she would be loved and cared for.

-Kristin Cameron

References:

Berry L, Biersteker L, Dawes A, Lake L & Smith C. (2013).  South African Child Gauge 2013. Cape Town: Children’s Institute, University of Cape Town.

DHS. (2007). Physicians guide for reporting suspected child abuse and neglect. Retrieved at 11:00 on August 17, 2014 from http://chanceatchildhood.msu.edu/pub.html

Flaherty E, Sege R. (2005). Barriers to physician identification and reporting of child abuse. Paediatric Annals 34 (5): 349-356

DSD, DWCPD and UNICEF. (2012). Violence Against Children in South Africa. Pretoria: Department of Social Development/Department of Women, Children and People with Disabilities/UNICEF.

Prato N, Morris L, Mazive E, Vahidnia F, Stehr M. (2006). Relationship between HIV risk perception and condom use: Evidence from a population based survey in Mozambique. International family planning perspectives, 32 (4): 192-200.

StatsSA. (2014). Work & Labour force. Retrieved at 10:00 on August 17, 2014 from http://beta2.statssa.gov.za/?page_id=737&id=1

Advertisements

What is religious freedom anyway?

I was struggling to get inspiration for a post then I remembered how I enjoy talking about religion and maybe I could think of something relating to that. I love watching Grey’s Anatomy and I remembered watching an episode about an ethical dilemma (of which there is no shortage of in the programme) which involved a strong religious view. I found it, and re-watched it, now finally I have my inspiration for this post 🙂 

The dilemma

In episode 13 of season 9, a teenage boy is rushed into the ER after sustaining serious injuries after getting hit by a car while skateboarding. The boy has some serious heart problems and is losing a lot of blood, he desperately needs a blood transfusion. The doctor orders a few units of blood and at that moment a tag falls out from the boy’s pocket, which says that he is a Johovah’s Witness, which changes everything. Johovah’s Witnesses cannot accept any form of blood transfusion, even in life-or-death situations. 

The doctor is forced to stop the blood from being administered, perform heart surgery without any extra blood and watch as she does everything she possibly can to save her patient before he passes away. An intern doctor felt horrified at this situation and tried acting against her orders by giving him blood, she was caught out just before it was connected to him. She could not understand how you could abide by a religious rule that she thought was not at the best interest of the patient. 

The patient soon passed away.

The problem was that the patient was a minor and his parents had to make the decision to not give him blood. The child could of had a different religious belief and if able to might of made a different decision. But the doctors had to trust that the parents included this into their decision-making process.  

Is religion really that important? 

We as medical professionals need to respect each and every view of our patient, including their religious beliefs, because that is what’s important to the patient. Even if it differs from our own beliefs. Religion is often a huge part of a patient’s identity and it is just as important as every other aspect of the patient’s life. It would be wrong not to respect it.

But should a religious rule control medical decisions, especially ones that are in conflict with ‘the best medical treatment for the patient’? Who even determines that? 

On the other hand

Being a doctor and having to make that decision must be so hard. It is (for some) going against your own morals, going against your innate tendency to do good for your patient. On the one hand you would be going against the patient’s right to the best medical treatment, but giving the patient treatment that is contrary to the their belief would not be giving the patient their right to autonomy. To go against something you believe in for the sake of remaining ethically correct is hard. Incredibly hard, impossible for some.

What is the solution?

There is no easy answer. In the end, you cannot break ethical code just to satisfy your own needs. Finding a solution should be personalised because we are all have different beliefs. Somewhere in the process we need to change our mindset that spirituality is important and needs to be taken into account. And sometimes we need to accept that we may not always know what is ‘best’ for our patients. 

I personally would find this really hard if I were in that ‘Grey’s’ situation, I would feel very conflicted. But it doesn’t come down to what I feel, it comes down to what is right for the patient and I must learn to accept that. 

Pain Management

Would you ever under-treat a patient’s pain because you were concerned about repercussions or because you believe that a patient – even a terminal patient- might become addicted? 

Image

This was a question asked to doctors in a survey. 84% said no, they would give their patients the pain medication, and one of the most striking reply to the question was this: “Pain should not be undertreated, and what’s the problem with a terminal patient being addicted and comfortable?”

A patient’s perspective

Struggling with immense pain, especially pain that severely impairs quality of life is a problem. A huge problem.  I found 3 quotes very useful in getting an idea about how detrimental pain can be:

“The most frightening, the most humiliating, and the most difficult ordeal of my life . I became withdrawn, completely disabled by my terrible, relentless pain. I was unable to function professionally. I was unable to be much of a wife or a mother, a daughter or a friend.”

“Pain is my biggest fear, it puts me in a darkness, you can’t find peace in that darkness of pain. Pain blinds you to all that’s positive.”

“They wanted to know why the medication was not working? Why are you still in pain? If you are crying, why are you crying; if you are not crying, how can you be in pain? You are not only experiencing your pain, you are experiencing other peoples’ opinions and feelings; that makes it worse.”

Pain now seems much more than a ‘highly unpleasant physical sensation caused by illness or injury’. True pain is much deeper than that, it’s more like a torment of one’s entire being, physically, emotionally and spiritually. Most people would do almost anything to relieve their pain in some way, even if it was just a small amount.

A doctor’s perspective

Most medical professionals would do as much as they could for patients to be comfortable, but some won’t because they are scared of the possible legal implications. We were taught to always have the patient’s best interests at heart, and thus  the relief of pain is a core ethical duty in medicine.

But why then is pain not always correctly dealt with? Some medical professionals do not treat pain sufficiently, patients lie about pain and most people do not know what to do with chronic pain.

I was told a story once of a patient who was diagnosed with chronic pain after a car accident. A physiotherapist had convinced her that she needed physiotherapy everyday to help her with her pain, she was told if she did not get her knots worked out everyday it would snowball and the pain would become unbearable. This is a perfect way to ensure your patient will believe they have pain and to make sure you get money every day. But completely unethical.

Another example is a patient who was previously a drug addict and lost everything. He then decided to make up a story about an accident he had a few months ago and he has been is such pain ever since, hoping the doctor would prescribe narcotics to give him his fix.

How do we deal with this problem?

I think with experience you can pick up on small signs that the pain is real or not, but there is a fine line there. I also believe that chronic pain is more psychological than just physical and needs to be handled properly. It is easy to jut handle the chronic pain patient by prescribing them the medication they need every month and sending them on their way, but it needs to be addressed at a deeper level and that is why a multidisciplinary approach is a good idea. Sometimes all a patient needs is somebody to explain what chronic pain is and how it works and the pain already decreases.

Real pain should not be pushed aside, underestimated or undertreated. Treatment for pain can be quite complex, but it is possible. Personal and professional accountability for failing to treat patients competently and compassionately is critical, but so is creating environments that make effective care for patients in pain the norm.

When personal information becomes too personal

While working in a hospital setting, it is quite common to have interdisciplinary discussions about a patient or to share your experiences with your peers. I believe that this is important because patient management should involve all medical professionals who need to communicate with each other in order to provide a holistic service to the patient. And sharing our experiences with our peers assists in the reflective process and learning more about conditions that we wouldn’t have known about without the input. But when the conversation is no longer patient confidential and it turns into an in depth conversation about the patient’s social history and we seem more judgemental than anything else, how do we react? 

There are many examples I can give, these are just a few:

I was in a patient’s room while two doctors were seeing the patient, when they started discussing the patient’s alcohol problem and why this is leading to her stubbornness and difficulty treating. They started making jokes about how she’s actually being forced to go ‘cold turkey’ and the only reason why she’s being difficult is she is craving a drink. All of this was said in front of the patient. And I was standing there thinking that this was so wrong, but I actually found myself joining in the conversation in order to ‘fit in’. 

I was told that I had to see a patient that was also a prisoner. This freaked me out and I was not sure how to deal with the situation because it was a first time for me. So I resorted to what I know best, and I spoke to a peer about it. It would have stayed confidential but my peer knew exactly who I was talking about as she had seen him previously. We discussed details of the patient, which I knew was wrong but I was relying on her information to ease my mind.

And many a time I have overheard nurses, doctors and physiotherapists share information about patients I wouldn’t dream about sharing. I know the workplace can get boring but turning the patients into some form of entertainment is wrong.

 

The patient’s right charter states:

Information concerning one’s health, including information concerning
treatment may only be disclosed with informed consent, except when
required in terms of any law or an order of the court.

According to this law, we have been doing things wrong. I searched for something that would help me with this problem. I found a great article, in it, it states that the duty of confidentiality requires that doctors keep secret the information they are given by patients and/or that they discover or learn about patients through their professional interactions. And some commentators have argued that breaches of confidentiality are a normal part of contemporary healthcare.

From a patient’s perspective:

If I was a patient, I know I would not appreciate health professionals discussing something about me that is personal. I would consider that as a breach of confidentially. If it has nothing to do about my condition and management, why do they need to discuss it? Overhearing them would decrease my trust in my medical team and make me feel violated. I wouldn’t want to share anything else with my doctor, even if it was important. 

From a professionals perspective: 

From a professional’s perspective, I would appreciate knowing details about a patient that would assist in my management with the patient. Discussing personal information might help me get a better understanding of the patient. In some cases it would be easier if one person interviewed the patient on all their personal and social information and we all got to share in that information, but since it doesn’t work that way I would either have to ask the patient or a medical professional that knows more than I do. It’s more convenient to ask a professional because then you don’t need to be aware that the patient might not appreciate you asking them that question. 

Where to go from here:

After reading through the article about patient confidentiality, I have realised how common patient’s experience a breech in their confidentiality. And I know that I am to blame for this problem. Next time I will not engage in conversations that involve in depth information about the patient and I will try to get the information that is relevant to me from the patient instead. I am definitely more aware of what kind of information is okay to talk about with my peers and what to avoid, and I will try be more careful about what I share and choose to listen to. 

When our superiors are in the wrong

How many times have you been told something by a superior and you know it’s wrong but you won’t disagree with them because you feel that your opinion is not valid or you just don’t have enough information to back up your argument? What happens when they are feeding you information you know you should not be getting from them but you listen anyway because it can benefit you? This happens all the time in the clinical context and it really gets on my nerves. 

When preparing for my clinical exam, I know that I may not get any information from my clinician because the exam needs to be a true reflection of what I can do on my own as a physiotherapist and not rely on somebody to help me. Of course I would love information that could assist me because I want to do well but I know in my head that if I did get help I wouldn’t see that as a true reflection of what I can do. So I avoided my clinician the day before my exam and she seemed to appreciate the fact that I was not asking her questions.

But the next day I overheard that some of the other students were asking their clinicians for information and assistance. And it was interesting to see the clinicians’ reaction to the students request.  Some refused, some first refused then started giving hints about the patient’s condition, and one actually helped a student come up with a treatment plan. That’s not fair, is it? How does it help future patients if you are’t willing to put the effort into finding information out yourself? And surely after 6 weeks at a block you should have gained enough learning to make your own sound decisions? Does getting a pass or a good mark outweigh the need for you to be a good physiotherapist? 

And this is where clinical reasoning comes into play. Clinical reasoning is “the sum of the thinking and decision-making processes associated with clinical practice”. What a necessary skill to have. According to Atkinson H & Nixon-Cave K clinical reasoning is becoming a large part of professionalism and is being used to assess students. But do examiners actually pick it up? I would hope that an experienced examiner would pick up that you have a sound understanding of  the patient’s condition and create an effective treatment based on that understanding. If not, I could just get as much information as I want about a patient and memorise it and give a false view of my understanding and do well in my exam. Sure, you get a good mark, but how does that help anybody? In the end, if you just recite things without understanding them then you have actually gained nothing, and neither has your patient. 

The patients that student physiotherapists see in the future are relying on their ability to assess them correctly so that they can treat them effectively. If a student doesn’t put the effort in at university to learn this, then how are they going to behave when they graduate? 

On the other hand, the clinical environment is quite competitive and if a student does badly, does that reflect negatively on their clinician? Is their intention to help you pass in order to make them look good? I think this has a part to play.  I have personally experienced doing well in a clinical exam and my clinician saying that I only did well because she is a good teacher. And I have also experienced a clinician putting unnecessary pressures on students to do well after another student got an A. 

Putting all this information together, I feel that not having competent clinical reasoning would shine through no matter how much external help you get. It is unfair that clinicians assist students because it is not a true reflection of the student’s ability. Next time I see this happening I would like to speak up instead of being quiet about it. 

Is being abused now part of our job description?

Recently a nurse told me a shocking story about her friend, (also a nurse), who was kicked in the face by a patient who she had not provoked in any way, while the patient was fully alert and could comprehend what was happening at the time. She had severe problems with her neck afterwards, and made a formal complaint to the workers compensation fund. At the hearing, the patient reported that he was in ICU at the time and was probably high on medication because he did not remember the event. The nurse was sent home with no compensation what so ever and many years with neck pain to follow.

How is this okay?

We talk about patients being mistreated, but what about medical professionals being mistreated? This is a problem so often ignored. And if nothing is done about it, abuse in the workplace can start to become ‘part of the job’ for some individuals.

How bad is the problem?

There are many studies on this exact problem, mainly focussing on nursing staff, and after reading a few I can understand why. A study was done in Australia and it was found that 92% of nurses had experienced some form of verbal or physical abuse in the workplace. In another study was done in an emergency ward, it was found that there are approximately 5 episodes of violence against staff by patients a week. These episodes include being sworn at, pushed, hit and kicked by patients. Another major problem is that most violated staff feel there is inadequate support for them so they would rather not seek help.

My own personal contact with this issue:

I personally have not experienced any situations where I was verbally or physically abused by a patient but I have frequently found myself in a position where I feel unsafe with a patient. I continue treating the patient because I feel obliged to by the system. “I’m a student, what do I know anyway?” After being subject to abuse in my personal life, I am sensitive to these situations and do not handle them well. My safety becomes my first priority and I avoid physical contact as much as I can, and since physiotherapy is a hands on job, this causes a dilemma.

According to the National Patients’ Rights Charter, every patient has a right to a healthy and safe environment that will ensure their physical and mental health or well-being. I need to ensure that the patient gets treatment that is beneficial to them. But I feel unsafe to touch the patient. What do I do? I have the right to a safe working environment. I do not have to treat the patient if I feel unsafe but I don’t want to get into trouble with my clinician and cause a scene. Can I just settle on treatment that does not involve much physical contact? Or do I make an effort to report how I feel to my clinician?

Conclusion

It is a fact that many health professionals experience abuse in the workplace and it is vital that something is done about it. We should be encouraged to talk about such things and stop believing that its just part of our job. Bullying is never okay.

Introspection

Image

 

I’m a third year physio student at UWC doing a course on ethics. For my course I started this blog and posted posts on challenging topics over the period of six weeks. This is my final post for the course, but the beginning to new things. 

I am quite sad to be finishing off this course. I have so enjoyed networking with others from all over the world, and I will miss having something stimulating to think about each week. I feel a need to carry on with something like this. This week I would like to address each question we were given individually.

1. Have my expectations been met? 

To be honest, my expectations were not too high for this course. As for students usually go, they do things because they have to. This course was one the many things ‘I had to do”. But as soon as I started the first week, I enjoyed the challenging topic of Empathy, it caused me to think, and think hard. I expected to not enjoy exposing myself to the world, but for once I really felt like I was being heard and express myself freely, something that boosted my confidence. According to this article, blogging as a communication and learning students between students is quite effective, and I agree. This blog was very effective for my learning, so it exceeded my expectations.

2. What did I learn? 

Where do I start? I’ll start with the simpler things:

  • Firstly I learned how to blog, the fact that I’m writing this is evident enough.
  • I learned the importance of networking with others. Challenging each other’s views and opinions appropriately makes you challenge your own views and options, causing possible personal growth (if you’re open to it).
  • I learned how to have effective conversation. I found this article, “What’s wrong with playing Theology Police?“, and found it so stimulating I had to blog about it. It was about how we shouldn’t talk unless were are prepared to listen, and how we should be faithful to our beliefs but not have a driven egotistical need to be right all the time. You can read this post here.
  • Empathy is essential for life, especially for health professionals. After reading Alexa Pohl’s post on empathy, I found a great series of videos on YouTube which explained empathy in a really simple ways and noted the importance of it and ways to develop empathy. You can find this series  here.
  • Morality shapes the way we act. Our moral values are determined by all kinds of things during our development, but however they are formed it is important they should benefit humankind and not destroy it.
  • All humans are equal but we place different value on different people. Racism, homophobia, xenophobia and other controversial topics should not be an issue in this day and age. Although, we place value on the lives that are most meaningful to us, such as our family and friends and often feel morally loyal to the lives that are most dear to us.
  • Morally ambiguous topics such as euthanasia have no easy or one right answer. It continues to be complex and should be treated appropriately.

3. Will I change? 

Yes. I think this course has stimulated my thinking and thus challenged my outlook on how I should go about seeing and treating a patient. I believe that who we are with our patients should reflect the person we are on the inside and who we in all other contexts.

I have challenged myself to rather be empathetic than to be sympathetic, to respect other people’s points of views even though I may not agree with it and to listen more. But I think most importantly, especially with regards to patient care is I have learned the best way to go about responding to their questions in an appropriate way. Our response should be objective, present both sides of the argument and be able to make the patient feel safe enough to make difficult decisions without feeling judged. I know that I need to work on that, especially to not letting my own personal views take control of conversations.

I know all these things I have just mentioned cannot be developed overnight or even be mastered in a few months, but it is a journey that will continue throughout my life. This course was the start of the journey and I look forward to the new challenges ahead of me.

Thank you to all who read, commented, challenged and replied to this blog, it was necessary for my growth and I appreciate it!