Compassion is a word that means different things to different people. It is a nebulous concept and, along with the terms dignity and suffering, is often considered “soft” and not particularly relevant clinically. Mainstream literature has tended to focus on “compassion fatigue” among healthcare professionals rather than on the delivery of compassionate care to our patients. It is therefore very encouraging to see research being conducted into compassion from the patient perspective within the New Zealand context, and for it to be published in a journal with broad readership. We congratulate the authors for their work and recommend that readers ponder on their own practice and consider how to be more attentive to this issue.
Everyone in health accepts it is important to be compassionate, but the busyness and complexity of modern clinical practice tends to push it to the periphery. Like communicating bad or serious news, it can be seen as hard to do well and something that needs a great deal of time, when time is so often in short supply. In this article by Fernando et al,1 the voices of articulate and thoughtful patients are heard as they reflect on the meaning and importance of compassion. They have given their time and energy even as they face the end of their lives. They have framed these complex concepts in a way that helps make the delivery of care in a compassionate manner more understandable and achievable, and in our view they have created a vision for the future of healthcare in our country.
Four themes were identified by the 20 patients who contributed to the Fernando study. The first theme is connection, and is completely unsurprising. It is how we function as human beings and is even more critical at times of stress such as acute or progressive illness. Establishing a clinician-patient relationship requires a connection to be made, both from an intellectual perspective as well as an emotional one. The two are intimately entwined. Making a connection and seeing the patient as the priority is the foundation of the therapeutic relationship. Sometimes patients come to palliative care battle-scarred and demoralised by previous clinical interactions. In these situations engaging with them and “seeking to understand” their needs is often able to facilitate an instant connection.2 Connection encompasses understanding and empathy, both of which need to be exhibited and modelled in the clinical setting.
The second theme, presence and warmth, describes the way patients wish to experience our care, using words such as being positive, uplifting and friendly. Sometimes it is “as simple as sharing a smile or a joke”. It encompasses both physical and emotional elements.3 Practising in this way does not cross professional boundaries as was once believed, neither does it minimise or trivialise the issues. It may not require long periods of time but does need insight into how we behave and present ourselves to patients.
Respect as a theme encompasses virtues such as being heard, not being judged, and being valued as a “full person”. It requires eye contact, openness and honesty. Often health professionals appear to compartmentalise medical issues, separating them from other aspects of their patient’s lives and regarding them as less important. This is inappropriate and completely dismisses the importance of community, the need to maintain roles and relationships and the capacity for support to exist outside of institutionalised healthcare. It is important for patients to be treated as “intelligent individuals” and not as conditions or numbers. They want us to be “fully present”—to be attentive. This is another skill that doctors can and should learn, encourage and value.
The final theme is caring. The Fernando et al paper describes this as a complex theme incorporating many subthemes; encouragement, reassurance, support, comfort, commitment, responsiveness and sensitivity. Everyone reading this list would want to be treated this way in our health system and would want this for their loved ones, especially (but not only) if they are facing a life-threatening diagnosis. With the power balance in favour of the medical professional, this is the least we can do for the people we are treating.
Despite this study being restricted to hospice patients, and involving mainly older people from one centre, our collective experience across the wider health system would suggest that the findings are generalisable to the vast majority of people facing life-limiting illness in every healthcare setting. It is commendable that the study includes patients from several cultural backgrounds including Asian and Pacific but a deeper exploration of the cultural perspectives around compassion would be valuable.
It is interesting to compare and contrast this local paper with studies done internationally. Sinclair et al recently published a paper in a palliative care journal outlining the distinction that patients themselves make between sympathy, empathy and compassion.4 The term compassion was remarkably described as “altruistic, proactive and subtle”. In palliative care, these intriguing concepts are often debated and discussed, but across the wider health system there is generally not the forum to do so. The words sympathy, empathy and compassion are commonly used interchangeably but it is clear that they are quite different from the patient experience.
Communication is also a recurring theme when considering the patient-healthcare provider relationship and needs to be supported at all levels. Communication skills training (throughout our careers, not just at undergraduate and trainee levels) as well as opportunities for peer review and reflective practice should be widely available and universally supported.
Ideally, a whole of system view of compassion in healthcare is needed, not just a personal or professional one. A report released by the National Health Service (NHS) in the UK for nurses, midwives and care staff in May 2016 focuses on this issue.5 The report is called “Leading change, adding value”. It describes “overwhelming support for the 6Cs: compassion, care, commitment, courage, competence, communication” and identifies compassion as the “foundation of our value base”. A similar focus here in New Zealand would be extremely timely and transformational.
For doctors to truly heal those who require our skill and guidance, we need to find not only empathy, but compassion, that virtue which our patients state is central to medicine.