For the purpose of this book,
‘mourning’ indicates the process that occurs after a loss and is fairly
universal and fairly predictable. Mourning is not a psychological/emotional
state of being
Grief refers to the personal
experience of the pain of the loss.
The bereaved person often regards
feelings of depression as ‘normal” (even although they may seek professional
help).
Freud suggested however that in
grief, the world looks like a poor and empty place, whilst in ‘classical’
depression, the person feels poor and empty inside.
Emergency Medicine Services (EMS)
health-workers generally have a low regard for “mental health” or psychology
and psychiatry; and often for reasons that reflect more on their own personal
inner-dynamics, than on the validity of psychology.
In fairness though, when you spend
your days doing aggressive, invasive, bloody and often quite bizarre things to
complete strangers, then you do tend to develop a preference for action, a
tolerance for adrenaline and a distrust of professionals who are outside the
dynamic of immediacy of action.
Nevertheless there are some
profoundly practical reasons why psychological tools appear to be
unworkable in the acute care setting, and in particular in pre-hospital care.
There is a belief still popular and
current in psychology that the “client” has to recognise that he has a problem;
and then that he needs to seek therapy himself.
Frankly, that approach often fails
the acutely traumatised person who is unconscious and bleeding to death. So to
does the belief that “the patient is his own doctor”, and will with time, be
able to heal himself if the problems are reflected back to him.
This simply does not work in the
grief-process experienced in the majority of acute-death, disaster-death or
terrorist-death situations.
Rather, the patient needs to be cared for, to be
given a list of things to do; a list of the problems which he may encounter;
explanations need to be offered; but principally, the acutely bereaved patient
generally needs to be told what to do,
if only practically; and only then may he be facilitated through the grief
work.
Traditional therapists voice
the concern that “before the term counselling became common currency for
many forms of ‘giving advice’ (which
it is not) the caring professional knew about listening and paying
attention.
But this is often in order to
prescribe a rescue package, the essence of which is: ‘I know what is best for
you’”. (Alan Burroughs, NT, May
17,1989,v85, n20)
I would never ever presume to know
what is best for you as an individual as you go about your daily life. But
standing in a resuscitation room, then frankly, its my job, it’s the point of
an extensive and expensive education to know what is ‘best for you’ in this one
particular situation.
Or at least to give you an idea of
where to start your own mourning process.
But like any other interaction I
might have with any other conscious patient, its always only advice I am
offering. You may choose to take the advice or ignore it.
So the trauma nurse is not ‘handing
out a cure’ per se. She is presenting a model of behaviour, - a roadmap
through the grief-, to empower the patient, and this with the suggestion that
the patient does the work under the direction of an outsider who is preferably
a grief-counsellor.
The model
that may work in more mainstream and popular areas of modern counselling is
simply not true of acute bereavement. Marriage counselling
for example, which requires an implicit drive to change your life for the
better, and at which self-selected attendance makes sense, is light years
away from the reality of a 4am cot death. This ‘event’ simply leaves the
parents marooned on an island of despair. Death has done its own self–selection
without consultation with the parents.
It simply cannot be
overstated.
There are no second chances for
bereaved parents. There are no “come back tomorrow and let’s try something
else” counselling opportunities. Time has run out.
To abandon them to a traditional
model is unethical, immoral and frankly naïve.
So for the purposes of this protocol,
lets accept that the patient or relative may, - to use a Transactional Analysis
tool-, need to be treated as a “child”,
-dependent, for a very brief period of time, and within a very rigid
framework-on a “parent”,
who is the grief counsellor or nurse. In essence is exactly what happens in any
Resuscitation Room, with no other purpose or intent except to try and save the
life of an unconscious stranger; someone over whom you will never again hold
any power; and would, in an ideal world not wish to be holding any form of
(resuscitation) power ever.
This is simply not an exercise in
negativity or power manipulation.
Emergency medicine, unlike just
about any other field of medicine, requires that the patient voluntarily
‘suspend their power’, and let the staff perform all sorts of invasive and
unpleasant procedures on them or their loved ones; let them take absolute
control, and to do this often when the patient is unconscious or is in an
altered state of consciousness.
So here are two unique requirements
of EMS.
Firstly, there is the requirement
that you actively physically treat the patient before you often have a
definitive diagnosis, beyond the obvious presenting condition. And an
understanding that ‘diagnosis’ is often a fluid and rapidly changing set of
physiological parameters that require intervention from any number of staff.
Secondly, there is a ‘common understanding’
or assumption that you will do whatever is required to save the patient’s life.
And that you will do whatever is necessary without getting consent, if the
patient is alone and unconscious.
There is a presumption of
care, predicated on both the training-, and ethos-, of the practitioners;
and of course, on the actual nature of the work.
Most “Consent to perform an
Operation” forms will have a paragraph which reads that “the patient gives
consent not only for a specific procedure, which has been discussed with
them and explained to them, but also for ‘any further or alternative operative
procedures as may be deemed necessary’”.
In EMS there is frequently no time
to discuss anything. So patients are as a matter of course, treated as
children; i.e., their rights are temporarily suspended due to the
extra-ordinary nature of the situation; and based on the assumption that you
are the expert at this one thing; and that your power over them is limited,
finite, compassionate and is always as part of a reflective team.
It makes
sense therefore to assume that the emotional or psychological care of the
acutely traumatised patient be handled in the same way initially.
Peter Brown, a bereaved father and a
Nurse says the following. “Although I am a Nurse, I write this in my capacity
as the father of Joshua, a robust laughing toddler, who died suddenly after
being ill for less than 24 hours. He was a week short of 19 months old. Looking
back on these sad events, we feel that we got some very useful advice. At a
time when our ability to make decisions was impaired by grief, we needed help,
for example, with choosing between burial and cremation; and if we chose the
latter, what to do with Josh’s ashes.”
Specifically he said “We
needed to be forewarned of some of the symptoms of the mourning period (of
things) which make you feel sure you are going mad.”
(Paper given at the Second Int’l Conf on Children &
Death, Edinburgh, 1992)
No comments:
Post a Comment