Thursday, October 10, 2013

Vignettes: Emotional Contagion

A daughter wrote a letter of complaint, essentially about my lack of empathy. I was reminded of this reading The Managed Heart which discusses the work of feeling and feeling rules.

The daughter brought her mother to A&E on a Monday, which is almost always busy, because she had fallen and sustained several gruesome looking soft tissue injuries, most dramatically of her face. This happened early on Saturday morning after she had been out drinking on Friday night.

There was some urgency to attend to her because her husband was dying, literally, in a palliative care facility due to a metastatic brain malignancy and they wanted to be with him for his last few hours. All understandable.

Being the conscientious doctor that I am, I reviewed her previous attendance records and found that she had been discharged the afternoon previous after a thorough assessment, including CT scans of her brain and cervical spine, and a lengthy period of observation.

So, after introducing myself and acknowledging that she was being seen immediately because of her husband's pending death, I asked, "Why have you come back today?" Quite reasonable I think considering that she had been discharged less than 24 hours earlier.

It turns out that she had been drinking excessively because of her husband's health problems; that she had fallen down drunk and then lost consciousness on a public road, from whence an ambulance brought her to A&E. When she was well enough, in the department, she was asked, as per protocol, who to contact regarding her admission. She listed her daughter as next of kin but refused to have her contacted. She refused again at discharge, declaring a preference for a taxi hire. She did not want her daughter to know that she had been admitted to hospital for more than 24 hours because of injuries sustained due to acute alcohol poisoning.

So, her daughter who had last seen her a week before was entirely unaware of the events of that weekend. Concerned and already grieving for her father she brought her mother in for treatment.

I examined the mother and found nothing substantially different from the afternoon before and explained that the injuries looked much worse than they were and that once the swelling resolved - another three or four days - things would look considerably better.

During this conversation the daughter had burst into tears. And I had failed to acknowledge her obvious distress. In explanation, it was the first anniversary of my father's death and managing my own grief without expressing it at work was already hard work without the additional stress of her emotional contagion.

And I did not believe that I owed her an exposition of my own loss or it's expression. It was not my fault that their family dynamics had become so dysfunctional under the stress of her father's dying and her mother's inability to cope and her lack of sibling support.

She was angry and guilty and afraid and anxious and quite overwhelmed. I know.

Neither her mother nor her father were legitimate targets and so she took the time to write a letter about my lack of human feeling, which lack was particularly egregious given my profession.

I wrote a letter of apology for my perceived lack of expressed empathy and/or sympathy. It said nothing about my own grief and the work of managing it. And it very deliberately said nothing about the communication failures within their family.

Patients, their relations and their friends pay lip service to the humanity of doctors and nurses without accepting the frailties that lead to such failures of communication as I have described.

Knowing is never enough. We all fail sometimes....

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