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Join guest Harvey Max Chochinov, a psychiatrist, as he delves into the profound concept of “intensive caring” in palliative care. Inspired by Dame Cicely Saunders’ powerful quote, “You matter because you are you,” Harvey discusses how this approach reaffirms the worth and dignity of patients who may feel they’ve lost their significance, shedding light on the universal need to recognize and support their humanity.

Harvey Max Chochinov is a psychiatrist.

He discusses the KevinMD article, “Intensive caring: Reminding patients they matter.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Harvey Max Chochinov. He’s a psychiatrist. Today’s KevinMD article is titled “Intensive caring: Reminding patients they matter.” Harvey, welcome to the show.

Harvey Max Chochinov: Appreciate it. Glad to be here.

Kevin Pho: So we’ll get into your article in a little bit. First off, briefly share your story and journey.

Harvey Max Chochinov: So as you indicated in the introduction, I did my medical training at the University of Manitoba and became interested in the interface between psychiatry and medical oncology. I went off to Memorial Sloan Kettering Cancer Center in the mid to late 1980s and studied with some of the real pioneers in the area of psycho-oncology, folks like Jimmie Holland, William Breitbart and Kathleen Foley. I came back to Winnipeg, and in the early 1990s I just kind of stumbled into the area of palliative care and palliative care research. One of the first things we looked at in our research was whether or not it was ever normal for people who were near the end of life to covet an earlier death. I found the intellectual engagement, the curiosity I felt, really quite astounding. And so one project led to the next, and I have really spent the entirety of my academic career in the area of palliative care, trying to explore what I think of as the experiential landscape of end-of-life care.

Kevin Pho: So talk to me more about that intersection between psychiatry and palliative care. What would you say are the major touch points where they intersect?

Harvey Max Chochinov: Well, a while ago I published an article that I called “The secret is out: Patients are people with feelings that matter.” Essentially, in contemporary medicine it’s all too common for us to become very, very focused on the biological dimensions of whatever particular ailment we’re talking about, whether it’s cancer or end-organ disease or whatever it might happen to be. But what I found during the course of my work, and have certainly substantiated during the course of multiple studies over several decades now, is that the human experience of being ill is something that needs to be attended to. When we lose sight of that, patients suffer, and they suffer because they feel that they have somehow come to be seen as the ailment that they have rather than the person that they are.

So large portions of my studies over the years have really looked at how we can ensure that personhood is on our clinical radar, and what we can do to safeguard it when we see the patient in jeopardy of patienthood somehow eclipsing personhood. Those are the critical touch points, and of course they have involved us delving into various facets of that. For instance, we have looked at issues related to human dignity in the course of receiving palliative and end-of-life care, and as such have developed instruments that allow us to measure and quantify dignity-related distress. We have developed brief interventions that give health care providers probes to elicit personhood, by asking something we call the patient dignity question: “What should we know about you as a person in order to give you the best care possible?” We’ve even developed psychotherapeutic approaches that are really based on the idea of legacy and generativity, so that somebody can create, for those they’ll eventually leave behind, a legacy that contains the essence of what they would want known, what they would want remembered and what words they would like to convey to the people who will outlive them.

Kevin Pho: Your most recent article was published in the Journal of Clinical Oncology, titled “Intensive caring: Reminding patients they matter.” Now, how did this particular article come together?

Harvey Max Chochinov: Well, I would say the inspiration for this article really comes from Dame Cicely Saunders. Dame Cicely, as you likely know, was the founder of the modern hospice movement. She founded St Christopher’s Hospice, and there was a very famous adage that she was known for: “You matter because you are you, and you matter to the end of your life.” That really has become the primary philosophical tenet of palliative and end-of-life care.

But what I began to think about, and what I realized, is that although that is so fundamentally important in terms of our mindset as we move forward in providing palliative care, Dame Cicely did not provide us with a template for how to remind patients they matter, for how to offer care that in fact embodies ways of reminding patients that they matter. So “intensive caring” was a bit of a play on words, recognizing that when people are in dire physical straits we provide them intensive care. But what happens when people are in psychological or existential or spiritual dire straits? What can we offer them? Well, we can offer them intensive caring, which essentially is a series of empirically based approaches that I review in that article, that really talk about how we can address, and be in the presence of, suffering.

Let me just back up for a moment to say that the elements of intensive caring include things like non-abandonment. The impulse, when we feel helpless and we feel a sense of futility, is to withdraw from care, and of course all of us have seen and experienced that, either personally or through mentors that we’ve been exposed to during the course of our training. And yet we know that if we remain present, we are able to make differences that are really quite profound. We can take an interest in who that person is. We can provide them affirmation that really underscores their continued sense of being worthy of honor, respect or esteem.

Another element of intensive caring is holding on to hope. Even while patients themselves may lose hope, if we are able to embrace hope, then it is the hope for achieving certain things that are still possible even toward the end of life: achieving a good death, being able to engage in meaningful conversations and meaningful disclosures even toward the end of time, giving patients and families an opportunity to express caring or remorse or love, or whatever it is that needs to be done during those times.

Another element of intensive caring has to do with an affirming tone, or what we’ve called therapeutic presence. That gives the message to the health care provider that, by virtue of your presence, things like compassion, being respectful and trustworthy and being fully present can provide affirmation that this person, in spite of their various encumbrances, still matters. Your presence matters, and they matter.

And then the final element of intensive caring is what I have coined therapeutic humility. This comes out of a study that we did looking at the elements of optimal therapeutic communication, a publication that appeared in Cancer a number of years ago. Therapeutic humility is really having the wisdom to step into a clinical scenario where you often don’t have a therapeutic fix. This really segues to a shift in paradigm that intensive caring talks about. In essence, the traditional medical paradigm is that we examine, we diagnose and we fix. I mean, that is the thing that brought most of us into medicine. What we eventually learn, though, is that there are things in medicine, and things in life, that really defy our ability to fix.

Now, that leaves us one of two choices. Either we say, well, anything that is no longer within the realm of the fixable is not in my lane, and so we withdraw, or we say, let the social worker or the spiritual care provider do that kind of care, that’s not my jam. Or we enter into those encounters yielding the idea that somehow everything we see has a readily available solution. So the shift in paradigm from examine, diagnose and fix is, first off, to understand who this person is. That is essentially our examination: to find out about personhood. The diagnosis then yields to how we understand the nature of their suffering. And the fix, by virtue of therapeutic humility, has to yield to this idea of providing comfort and being present with.

I think intuitively all experienced clinicians know that when you enter a scenario where you don’t have something that can reverse that depth of suffering, showing up matters. A patient has just died and the family is gathered by the bedside. What do you do? You show up. A patient has just had the horrible realization that they’re on a path very different from the cure they had hoped for. What do you do? You show up, not because you can shift that reality, but because being there makes a difference, and being there shows that in fact they matter.

Sometimes when people listen to me speak about this, they say, “Well, this sounds pretty touchy-feely. This is the soft side of medicine.” And I say, well, I think it’s a profound side of medicine. By the way, my most recent book is called Dignity in Care: The Human Side of Medicine. And I think all of us who are going to be practicing need to come back to my opening comment, that patients are people with feelings that matter. We need to embrace that, I believe, and it is the way that all of us need to provide care.

Kevin Pho: As you know, in intensive care settings in Canada and the United States, doing this may sometimes be in tension with how little time a lot of the clinical staff have. So what kind of tips can you share with clinical staff to incorporate some of these ideas in the everyday critical care setting?

Harvey Max Chochinov: Sure. Time is always a luxury, and having more time allows you to foster these kinds of deep therapeutic alliances. But one of the important concepts that emerges from some of the work we’ve done over the years is something we call the tone of care. This comes from studies we’ve done looking at what reinforces or undermines a patient’s sense of dignity. The tone of care, that aura, that quality, those ineffables about how you come across to the patient, not based on what you’re doing or what you’re saying but on your way of being, can make a profound difference in whether somebody feels embraced in your care and attention, or simply feels like just a patient. The great irony, of course, is that we train our entire lives to look after patients, and people get really pissed off if they feel that they’re being treated just like a patient, because “patient” is generic, “patient” is formulaic, whereas personhood and individuality are the antithesis of that.

So what I say to people who say we just don’t have the time is this: It’s about the tone of care. If you’ve got a minute, in that minute you can either make a good impression or a bad impression. It’s the same one minute. There’s a wonderful study, a randomized controlled trial of sitting versus standing on the first post-surgical visit by orthopedic surgeons with patients following spinal surgery. What did they find? Again, in this randomized controlled trial, the only thing that happens differently in the first visit is that the surgeons are randomized to either sit or stand the first time they meet with a patient after surgery. The amount of time that they sit or stand at the bedside is no different, just over a minute. But when the clinician sits, the patient’s perception is that they were there five times as long, and 95 percent of those patients report satisfaction with the encounter, versus only about 50 to 60 percent. Same physicians, same encounter, no change in what actually transpires, but when the clinician stands, only 50 to 60 percent report satisfaction. So I say time is a luxury, but in that time you can be an effective listener. You can be completely present if you choose to be.

The other thing, of course, is to point out what happens if we don’t take that additional time. There have been studies showing that the most likely reason you might be the subject of litigation is not medical misadventure but communication issues. People will forgive you almost anything, but they won’t forgive you a lack of kindness. So if you take the extra moments to be human and attentive, you will avoid the possibility of unhappy patients, avoid the possibility of litigation, and avoid discordance in goals of care. The other thing, by the way, is that we find in our studies that if you avail yourself of information pertaining to personhood, that is associated with heightened job satisfaction. That means if you engage in this kind of care, it is also going to confer protection against what we know, in the post-COVID era, has been a tsunami of physicians’ lack of well-being and professional burnout.

Kevin Pho: We’re talking to Harvey Max Chochinov. He’s a psychiatrist, and we’re talking about his article “Intensive caring: Reminding patients they matter.” Harvey, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Harvey Max Chochinov: Take-home messages. Well, again, I would return to the article I mentioned at the outset: Patients are people with feelings that matter. We need to know that. All of our patients have feelings, and those feelings matter, and if we’re not attentive to them, if we somehow see that as not being within our lane or scope of practice, we’re going to be doing a disservice to our patients, to their families and to ourselves.

Another take-home message: A number of years ago I published an article in the British Medical Journal called the ABCDs of dignity-conserving care, and those are meant to embody core competencies for anyone who deigns to enter into providing patient care. A is for attitude. Your attitude toward patients makes a difference. The way you see them and perceive them is fundamentally going to change their medical experience, their medical encounter with you. B is for behavior, and we’ve already reviewed how simple behaviors like sitting versus standing make a profound difference: meeting someone’s gaze, or not meeting someone’s gaze, and showing up. C is for compassion, your ability to recognize, besides the biological events that are unfolding, the human pathos of what happens in the course of providing care. So compassion is your ability to understand that, and your willingness to respond to it. And D is for dialogue: conversations with patients that elicit not only details about their clinical condition, but information about who they are.

And it doesn’t have to be complicated. Maybe I’ll end with one tiny vignette. I remember passing by the office of a wonderful medical oncologist, James Johnson, a very busy hematologist-oncologist, and as the door to his office was closing, the last thing I heard him say to his patient, and this is a very busy clinician, was, “So how was that vacation?” And the door shut. I promise you that minutes later they were not sitting looking through a photo album. But in acknowledging the person, what he was saying is that leukemia and lymphoma may not take vacations, but people do. So we need to remember that, and we need to incorporate this idea of personhood as something that needs to be on our clinical radar.

Kevin Pho: Harvey, thank you so much for sharing your perspective and insight, and thanks for coming on the show.