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ANALYSIS: Harvey Max Chochinov Dignity and the essence of medicine: the A, B, C, and D of dignity conserving care BMJ 2007; 335: 184-187 [Full text]

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Rapid Responses published:

The two-way mirror of patient care

Helena-Hermine Aitken   (29 July 2007)

The ABCD's of Dignity- A Roadmap for Improved Education

Glendon R. Tait   (30 July 2007)

Medical revalidation brings a challenge and an opportunity

Judy Wilson   (31 July 2007)

Cultivating compassion: seeing Patient Voices

Pip Hardy, Professor Paul Stanton   (3 August 2007)

Compassionate care : imaginative approaches to training

Simon JW Watson, Coventry House, University of Warwick Campus, Coventry, CV4 7AL, United Kingdom   (3 August 2007)

Dignity at the bedside, wherever that bedside is.

Hannah E. Leahy, Rachel E. Sheils   (4 August 2007)

Respecting dignity

David I Jeffrey   (6 August 2007)

Dignity in Care Campaign

Ivan Lewis   (17 August 2007)

Measuring the human aspects of care in medicine

Stewart W Mercer   (22 August 2007)

Dignity conserving care and the need to re-humanize healthcare

Daniel F Munday   (29 August 2007)

Patient Dignity - essential reading

John Wilson, John A. Wilson   (6 September 2007)

The two-way mirror of patient care 29 July 2007
Helena-Hermine Aitken, Pedagogical Coordinator of advanced post-graduate Palliative Care and Psychotherapist AMARA - Association for Dignity in Life and Death; 2660-215 PORTUGAL - www.amara.pt Send response to journal: Re: The two-way mirror of patient care	Many years ago, when I saw the photograph of a beautiful woman, on a shelf of a patient’s bed-room, I asked without thinking twice, “Who is this very pretty lady?” and my patient, severely disfigured by a terminal illness, started crying bitterly. Healthcare providers definitely have a profound influence on patients’ sense of dignity! I remember being appalled by both my inept lack of sensibility and its consequences; as well as the incredible difference between the photograph (taken only one year before the start of the illness) and the appearance of the woman in front of me. We are all “patients” – in the sense of being people who endure, bear and suffer, throughout life. H. Chochinov rightly says “patients look towards healthcare providers as they would a mirror, seeking (…) their continued sense of worth”. Equally true is the converse, that when healthcare professionals look at their seriously ill patients, they are facing a mirror of their own human condition. And this mirror awakens all their personal fears about suffering, at every level. It raises in them all the questions linked to the meaning of life. How can we prepare ourselves to look in the mirror of our own human condition? And be able to do so without entering into panic? How can we avoid fleeing busily into our technical actions, or suffocating our patient with overwhelming attention, which does little to respect his/her need for self-determination and dignity? How can we prevent frustration, hopelessness and exhaustion? I believe that H. Chochinov’s very practical guide to “Dignity Conserving Care” is going to be most welcome, especially to the healthcare providers who wish to “care about” as well as “care for” their patients. But in front of this two-way mirror, how can we develop the right Attitude that is advocated in this guide? I believe that we need to learn how to face, recognize and accept our own feelings about suffering and death. And we need to do this within the framework of a mutually supportive care team. The recognition that we are all “patients” helps us to accept our own vulnerability, and thereby the vulnerability and shortcomings of others. This effectively neutralises many things that can become a source of conflict within the team, and helps us to “speak the same language” as our patients. Not making assumptions or holding wrong perceptions about others obliges us to develop what I may call “our inner silence”. In other words, in caring for a patient, apart from the technical actions that we may have to perform to assure the patient’s biomedical needs, we need to avoid having any preconceptions about what the patient may think, feel, wish or need at other levels. Intention, even the very basic intention of helping, can be intrusive. Instead of “helping”, we need to be “accompanying” the patient; walking beside him, and ready to respond to his demand, at any moment, in the best way possible. Our sincere commitment to accompany the patient, by creating an empty space for “active listening”, allows the patient to express their real needs; so that we can then determine with them what we can do for them. In my opinion, such a quality of commitment helps us to face anything. It is an act of compassion that says, “I accept to share your suffering and your joy, to witness your fragility and your force, to embrace your despair and your hope”. Entering into a true Attitude of Compassion, which leads to the right Behaviour and to an effective quality of Dialogue, is not easy. However, we can fill the letters A, B, C, D with the human content advocated by H. Chochinov, by developing our “inner silence”, and recognising and accepting our individual and collective vulnerability: All this does not undermine our technical competence, on the contrary! We finally also need to find ways that help us to broaden our vision of life, and increase our understanding of the human condition. This can be achieved through the means proposed by H.Chochinov in his article. In addition, I would also recommend being in contact with nature and beauty. Nature and Beauty help us to put aside the personal preoccupations of our past and our future; they help us to be fully present in the present. We need to awaken our awareness of all that makes life worthwhile, from the simple gifts of our daily life, to the feeling of being part of a greater Life. My patient had reached the end of her life, apparently unable to communicate. Suddenly she became very agitated and screamed repeatedly: “I want to understand!” I got in touch with my “inner silence” and I felt all my being in a peaceful state of surrender. Spontaneously the answer to her quandary arose: “The time to understand has gone. Now is the time of surrender!” She stared at me and pronounced her last words: “Thank you! Your words have touched my heart!” Helena-Hermine Aitken Email: helena.aitken "at" amara.pt Director of Training AMARA - Association for Dignity in Life and Death www.amara.pt R. Alves Redol, 4-4ºC St. António dos Cavaleiros 2660-215 PORTUGAL Pedagogical Coordinator of advanced post-graduate courses on Long- Term and Palliative Care: (1) At the Instituto Superior de Ciências de Saúde-Norte (Superior Institute of the Sciences of Health) - http://www.cespu.pt (2) And the Escola Superior de Saúde de Beja (Superior School of Health) - http://www.essb.ipbeja.pt Helena-Hermine is a qualified psychotherapist and trainer of healthcare professionals. She also accompanies terminally ill people and their families as a volunteer. Competing interests: None declared
The ABCD's of Dignity- A Roadmap for Improved Education 30 July 2007
Glendon R. Tait, Resident in Psychiatry and Fellow in Medical Education The Wilson Centre for Research in Education, Faculty of Medicine, University of Toronto Send response to journal: Re: The ABCD's of Dignity- A Roadmap for Improved Education	Chochinov’s ABCD elevates his empirical model of “dignity” to a new level. It takes an empirically-based model and makes it practical and accessible for all professionals. It places dignity into a framework which indeed, as he alludes to in his last paragraph, should be a “duty” of every physician. Chochinov’s empirical model of “dignity” represents one of the most concerted, and rare, efforts to understand that dying patient’s perspective. Chochinov has shown dignity to be most highly correlated with “burden to others” and “respect”1. Previously he found that the desire for hastened death is more correlated with existential and psychiatric variables than physical variables2. However, medical education continues to focus on the physical aspects of patient care. Everywhere else in medicine, with empirical evidence as strong has Chochinov’s, clinical and, by extension, educational best practice, changes. However, in end-of-life care education, such evolution has lagged behind. Sullivan et al. conducted a large U.S. study of attitudes and preparedness in trainees in the area of end-of-life care.3 It showed that while trainees’ attitudes toward end-of-life care are remarkably positive, there were significant perceived deficits in managing patient’s thoughts and fears, attending to cultural and spiritual aspects, and, managing one’s own feelings. In a similar study of psychiatry residents in Toronto, we corroborated these findings, in a specialty that one would expect to feel particular competence in these very areas. We also found that while residents conceptualized dignity very similarly to patients, they felt grossly unprepared to deliver it.4 While some would argue that Chochinov’s dignity therapy, an empirically based psychotherapeutic interview shown to be very beneficial to patients, is not pragmatic for physicians of all specialties to practice, his current ABCD framework is not only attainable, but should be expected of every physician. It encapsulates exactly the kind of care we should be deliver to every patient, throughout the entire life span. Now having a rich, evidence-based, understanding of what dignified patient care is, from patients’ perspectives, we must align core competency, curriculum development, and assessment with the patient’s perspective. End-of-life care education, historically under-addressed, is finally receiving some attention. In Canada, end-of-life care is being defined as a core-competency that will translate to assessment on national licensing exams at the undergraduate and post-graduate levels of medical education. The ABCD’s of dignity conserving care should be reflected therein. This will mean setting the balance straight, one which thus far has been tipped to far toward knowledge and skills, mostly in pain and symptom management. Part of the lack of educational richness in psychiatric and existential aspects of patient care is rooted, as Chochinov points out, in health care providers’ reluctance to take ownership for those aspects. In addition, there has been a competition of sorts, where various specialty areas strive to advance their own definition of “good” care, partially because until recently we have not had the voice of the patient so strongly present in the evidence. Lack of attention to the psychiatric and existential aspects of patient care has also been neglected because medical training has not fostered enough attention to developing an awareness of the impact of one’s attitudes. Providing “dignified” care does not “belong” to psychiatrists or family physicians or surgeons or internists- it belongs to all of us. As such, curriculum development and assessment must move attitudinal development to the forefront of medical education. Hopefully as it becomes more engrained in us as professionals to examine our assumptions, including our own fears, we will be better able to “be” with the experience of our patients. Being aware of “another” means knowing the person’s story, which comes only, as Chochinov points out, through “dialogue”. And yes, because assessment drives learning, we must place more emphasis on whether a physician has come to really know the person and the person’s story. The ABCDs indeed provide a framework for curriculum and evaluation, not only for dying patients but for measuring attention to “dignity” and “personhood” in every patient encounter. Are attitudes, behaviors, compassion and dialogue difficult to teach and assess? Yes. But the time has come for the journey of medical education to be approached from a different vantage point- the patient’s. Chochinov’s ABCD’s of dignified care provides a great roadmap. Email: glendon.tait@utoronto.ca References: 1. Chochinov HM, Hack T, Hassard T, Kristjanson LJ, McClement S, Harlos M. Dignity in the terminally ill: a cross-sectional, cohort study. Lancet 2002; 360:2026-30. 2. Chochinov HM, Hack T, Hassard T, Kristjanson LJ, McClement S, Harlos M. Understanding the will to live in patients nearing death. Psychosomatics 2005; 46:7-10. 3. Sullivan The status of medical education in end-of-life care. A National Report. Journal of General Internal Medicine 2003; 18: 685-695 4. Tait GR, Hodges B. End-of-Life Care Education- Residents’ Attitudes and Perceived Preparedness. How do Psychiatry Residents define “Good” End-of-Life Care and “Dignity”? The Association of Medical Education in Europe Annual Meeting 2006; Genoa, Italy. Competing interests: None declared
Medical revalidation brings a challenge and an opportunity 31 July 2007
Judy Wilson, Independent consultant and patient adviser Impington, Cambridge Send response to journal: Re: Medical revalidation brings a challenge and an opportunity	As a patient and as a patient adviser I read Chochinov's article, Dignity and the essence of medicine: the A, B, C and D of dignity conserving care, with great interest. I was very moved by what he wrote. It recalled to me times when I have been ill, or my family have been ill or dying - often being treated with great compassion and preserving our dignity, but sometimes not. It is a very welcome addition to the literature and for education, of interest to clinicians and to patients. It rang bells for me, not only with personal and family experience but in relation to experience in my professional life while working in health charities and subsequently. The fundamental issue of dignity and respect, as is made clear, does not just relate to palliative care but applies across the broad spectrum of medicine. The good practice outlined so clearly coincides with what many patients and carers have been saying is needed for many years. Supporting self-management and self-care is an example of where this approach can underpin other developments too. 'Medical treatment and the way in which it is delivered can either support or erode the capacity to self care', (Dr Stephen Tomkins and Dr Alf Collins, www.dorsetsomerset.nhs.uk/documents/PromotingOptimalSelfCare.pdf) Medical revalidation will now bring both a challenge and an opportunity. In the new version of 'Good Medical Practice' much of the guidance on relationships with patients, including sections on the doctor- patient partnership, communication, and relatives, carers and partners, outlines requirements for doctors. Though brief, they coincide well with the concepts in Chochinov's article. The challenge will be to measure the extent to which doctors do put them into practice, harder to quantify than many other aspects of good medical practice, but essential in today's climate of patient partnership and collaboration. Judy Wilson Independent consultant and patient adviser judy.wilson3@ntlworld.com Competing interests: None declared
Cultivating compassion: seeing Patient Voices 3 August 2007
Pip Hardy, Consultant Cambridge UK CB25 9FA, Professor Paul Stanton Send response to journal: Re: Cultivating compassion: seeing Patient Voices	Cultivating compassion: seeing Patient Voices What a delight to read Professor Chochinov’s refreshing article about the essence of medicine. We applaud the ABCD of care and rejoice in the encouragement to see patients as human beings and not simply as their conditions. We have long known that compassion and respect lie at the heart of what most patients would regard as care rather than treatment – and this pertains to all patients, not only those nearing the end of life. We have also long suspected that stories are the best way to learn about what it means to be human. Our late colleague, Ian Kramer, a passionate advocate for more humane care for patients, noted that, for those experiencing illness, there are two types of journey; and the patient journey is only one part of the larger journey of life. For the past four years, my colleagues and I have been gathering the stories of patients, their carers and healthcare staff and presenting them as short (two – three-minute) ‘digital stories’ via the Patient Voices Programme. Although some of these stories are celebrations of the ‘value- based, scientifically informed artistry that characterises expert and clinically-governed care’ (Stanton, 2004), more often, we hear accounts of thoughtless treatment and careless care; pleas not listened to, common courtesy forgotten, mistakes not acknowledged, concerns disregarded. We recognise that herein lies a fundamental paradox: a malign alchemy. The overwhelming majority of those who work in health care are neither unprincipled, unmotivated, nor uncaring. Most people are drawn to medicine, nursing and other professional roles because of a desire to alleviate suffering and offer comfort. Nevertheless, in the turbulent 'here and now' of care delivery, under pressure of time, within environments that are coldly functional, operating from within the 'safety' of a powerful expert role and performing habitual and ritualised tasks that depersonalise the transaction of caring, the precious motivation of the professional is transmuted to a base and debasing inert compound. All too often, inhumanity is experienced by patients as a 'system property'. We share Gandhi’s belief that ‘the culture of the mind should be subservient to the culture of the heart’. In order to bring about transformation in our own practice and in the behaviour of the system, each of us must be able to reconnect to our own humanity and that of others and thus ‘be the change we want to see’. The stories that we have collected can be powerful prompts to reflection and to (re)learning profound truths that the pressure of the everyday can all too easily obscure. Working with our storytellers to edit and refine their stories, select appropriate images and music to complement the story, by a process akin to distillation, we reach the very essence or heart of the story, that which reveals what is most important for each patient/person. Precisely because they can be viewed away from the turbulence and immediate pressure of the here and now, the stories are moving and memorable in a way that can seem disproportionate to their brevity and apparent simplicity. Unlike so much policy, guidance and instruction, they are not prosaic, but have the resonant impact of a poem – what Wordsworth recognised as ‘emotion recollected in tranquillity’. In our experience, this can be true not only for those professional and other staff who work in the frontline of care, but also for those whose task it is to govern or manage a system that will only be sustainably humane if and when all of those within it are committed to the principles set out so eloquently by Professor Chochinov. Equally, in our experience, the creation of these stories is often an important step in the healing process of the storytellers. And we, listening attentively to every story, to what really matters to each and every individual who is courageous enough to tell an important personal story, are reminded of the greater story of our universal human experience. Over recent months, colleagues who share some of the concerns and aspirations set out above have been wrestling with the task of humanising healthcare. The Patient Voices stories have been both an inspiration and a resource. Like flashes of light from a lighthouse, the stories serve as ‘markers and guides, comfort and warning’ (Winterson, 2005) and are made freely available to all who can benefit from them. Each story offers us an opportunity to walk in another’s shoes for just two or three minutes. Each story is a plea to remember, in the words of one storyteller, ‘our own, quite common, humanity’. Indeed, the Department of Health (DH, 2007) reminds us that ‘The more our human rights are respected, protected and fulfilled, the more of our humanity or ‘what makes us human’ is fulfilled.’ Aware of the suffering of our patients, our families, our friends, ourselves, how can we do anything other than cultivate compassion, listen with attention, respect and do everything in our power to conserve the dignity of those who need care? If we are serious about putting patients at the heart of care, as the UK Department of Health (DH, 2000) says we should be, if we truly want to work in partnership with patients to co-produce care, if we want to care about patients as much as for them, then taking the time to listen to their stories is of paramount importance. It only takes a few minutes to begin a process of profound and potentially far-reaching change – as long as it takes to listen, really listen, to one patient telling a story. www.patientvoices.org.uk Pip Hardy and Paul Stanton pip@pilgrimprojects.co.uk References Department of Health (2000) The NHS Plan: A plan for investment, a plan for reform, Norwich: The Stationery Office Department of Health, 2007 Human Rights in Healthcare – a framework for local action, Norwich: The Stationery Office Stanton, P. (2004) The Strategic Leadership of Clinical Governance in PCTs, National Clinical Governance Winterson, J. (2005) Lighthousekeeping, London: HarperPerennial Wordsworth, W. (1798) ‘Preface to the Lyrical Ballads’, in Hutchinson, T. and de Selincourt, E. (eds), (1975) Wordsworth Poetical Works, Oxford: OUP Competing interests: I am a director of Pilgrim Projects and founder of the Patient Voices programme. Reimbursement for gathering and editing the stories allows us to make the stories freely available via the Patient Voices website www.patientvoices.org.uk
Compassionate care : imaginative approaches to training 3 August 2007
Simon JW Watson, Fellow in Quality Improvement and Honorary Consultant Nephrologist NHS Institute for Innovation and Improvement, Coventry House, University of Warwick Campus, Coventry, CV4 7AL, United Kingdom Send response to journal: Re: Compassionate care : imaginative approaches to training	Professor Chochinov’s framework may help health professionals to provide more compassionate and respectful care to our patients1. However great ideas alone don’t always lead to better practice, even when supported by training and re-training. We are all taught good practices as students but usually conform the habits of co-workers and bosses once we enter the ‘real world’ of work. Unfortunately bad habits contribute to the culture of our parent organisations and are become engrained and very hard to change. Replacing a bad culture with a better one requires will, leadership and good strategic planning however, as is often said in business circles, ‘culture eats strategy for breakfast’ 2. So how might we persuade people to adopt new and better habits? An interesting approach is suggested by Fred Lee in his remarkable book, ‘If Disney Ran Your Hospital’ 3. Lee explains how exercises in imagination are crucially important components of staff training at Disney (note - Disney are world leaders in customer satisfaction). Lee adapted Disney’s technique to training healthcare workers. He reports the case of a surly radiology department receptionist with bad interpersonal skills. Lee persuaded her to imagine that a patient were not a stranger but instead was her favourite aunt. The receptionist’s behaviour became far more compassionate and caring and – most importantly – the changes persisted. Lee’s book abounds with similar examples and he explains why these Disney- inspired methods beat many traditional approaches to staff motivation and training. Professor Chochinov has described a better world but real work is needed to get us there. New habits will only overcome bad cultures if also accept better ways of learning. 1. Chochinov HM. Dignity and the essence of medicine: the A, B, C, and D of dignity conserving care. BMJ 2007 doi: 10.1136/bmj.39244.650926.47. 2. McCracken J. ‘Way Forward' Requires Culture Shift at Ford. The Wall Street Journal, January 23rd 2006. 3. Lee, F. If Disney Ran Your Hospital : 9 ½ Things You Would Do Differently. Amer Hospital Association. 2004 Competing interests: None declared
Dignity at the bedside, wherever that bedside is. 4 August 2007
Hannah E. Leahy, Specialist Registrar in Palliative Medicine Yorkshire Palliative Medicine Training Scheme, Rachel E. Sheils Send response to journal: Re: Dignity at the bedside, wherever that bedside is.	Chochinov(1) is to be applauded for spelling out what should be common sense, but is often missing from patient care. The essence of his message can be summarised by the ethic of reciprocity, as a fundamental moral principle. This aspect of patient-focussed care is essential to the care of patients as individuals in all settings and we hope Chochinov’s framework can raise awareness of this. During our medical careers we have repeatedly seen patients' meals interrupted for the convenience of the doctor, and occasionally, patients reviewed while sitting on the commode because the ward round could not wait for them to be helped back to bed. The fact that curtains do not provide sound proof privacy can be frequently forgotten. As palliative medicine trainees, the issue of respecting our patients' choices often focuses on the preferred place of terminal care and death. While some patients will choose to die in hospital, a significant proportion of those who want to die at home do not manage to do so(2). While there will be practical barriers for some of these patients, the first barrier for professionals to overcome is the simple question, "Where would you like to be cared for when you are dying?" Perhaps respecting this choice restores for some individuals, the greatest dignity of all. 1 Chochinov HM. Dignity and the essence of medicine: the A, B, C, and D of dignity conserving care. BMJ 2007; 335: 184-187. 2 Daley A, Sinclair K. Recording and auditing preferred place of death. Palliat Med 2006; 20(6): 637-638. Competing interests: None declared
Respecting dignity 6 August 2007
David I Jeffrey, Consultant palliative medicine Borders General Hospital, Melrose, TD6 9BS Send response to journal: Re: Respecting dignity	Chochinov provides a perceptive analysis of dignity and dignity conserving care (1) It is refreshing to read that neither euthanasia nor physician assisted suicide have any part in dignity conserving care. Chochinov acknowledges that while the notion of dignity conserving care emerged primarily from palliative care, it can be applied across the broad spectrum of medicine (1). Chochinov’s A,B,C and D advocates trying to see the world through the other person’s eyes , an ethical model not just for medicine but for life. (1) Chochinov HM Dignity and the essence of medicine: the A, B, C, and D of dignity conserving care BMJ 2007;335:184-7 Competing interests: None declared
Dignity in Care Campaign 17 August 2007
Ivan Lewis, Parliamentary under Secretary for Care Services Department of Health Send response to journal: Re: Dignity in Care Campaign	I very much welcome Harvey Chochinov’s article and the accompanying editorial on the A,B,C and D of preserving patients’ dignity in the 28 July issue of BMJ. I support the view that attitude, behaviour, compassion and dialogue should be considered as important issues in the training and continuing professional development of the medical profession. Ensuring people are treated with respect for their dignity is an issue for the professional development of all health and care staff, not just doctors. It is within this wider context that I am personally leading, with the support of the National Director for Older People Professor Ian Philp, a piece of work from within Government to ensure older people and other groups in vulnerable situations are treated with respect for their dignity in all areas of care. We have already seen some significant successes, including a high profile Dignity in Care Campaign, establishment of a growing network of Dignity Champions, widespread support and involvement from key professional and advocacy organisations, strengthened regulation and inspection from the Health Care Commission, capital investment to improve the care environment and work on improving nutritional care. I look forward to continuing to work with the medical profession in this important area and invite anyone who would like to know about our work or to sign up to be a Dignity Champion to visit www.dignityincare.org.uk Competing interests: None declared
Measuring the human aspects of care in medicine 22 August 2007
Stewart W Mercer, Visiting Professor Chinese University of Hong Kong Send response to journal: Re: Measuring the human aspects of care in medicine	Like many of the rapid responses already posted, I was moved by the wonderful article by Chochinov on dignity and the essence of medicine [1]. As the rapid response letter by Tait points out , the ABCD framework of dignity conserving care proposed by Chochinov applies not only to doctors working in terminal care, but to all doctors, and indeed all who work in the caring professions. Given the current focus on biomedical and technical approaches to illness rather than the core values of kindness, humanity and respect, Chochinov's analysis is a timely reminder of the key importance of what Hart and Dieppe described as caring effects in medicine in their essay in the Lancet in 1996 [2]. Even in the growing field of patient engagement, the emphasis often appears to be on technical fixes or information sharing [3] rather than the fundamental problem of the separation of humanity and compassion from health care delivery [1]. Wilson's rapid response reminds us that revalidation of doctors bring both challenges and opportunities and raises the issue of measurement of the human aspects of care. Similarly, for doctors in training in the UK, sensitive and reliable ways of measuring and improving caring effects are now required for workplace-based assessment. Over recent years, myself and colleagues have developed and validated a patient feedback measure called the Consultation and Relational Empathy (CARE ) Measure, based on a theoretical framework of empathy in the clinical setting and heavily informed by the views of patients from across the socio-economic spectrum [4,5]. The validity and reliability of the measure is high in primary care [6] and we have now similarly robust and soon to be published findings in general practice registrars, and doctors in a range of secondary care settings including anaesthetics, medicine, and surgery. The ability of the measure to reliably discriminate between doctors (using G-Theory) in all these settings is high, with a feasible number of patients required per doctor (typically 20-30 patients to achieve an inter-rater reliability of 0.7 and 40-50 to achieve a reliability of 0.8). Further research is underway to assess the best way of feeding back scores and giving support to doctors in order to help enhance communication and empathy skills. Used wisely, the CARE Measure may be a useful way for doctors to self-monitor caring effects and to evaluate the effectiveness of activities aimed at restoring and/or improving the human aspects of care. [1] Chochinov H. Dignity and the essence of medicine: the A,B,C, and D of dignity conserving care. BMJ 2007, 335: 184-187 [2] Hart JT and Dieppe P. Caring effects. The Lancet 1996, 347: 1606- 1608 [3] Coulter A and Ellins J. Effectiveness of strategies for informing, educating, and involving patients. BMJ 2007, 335: 24-27 [4] Mercer SW, Reynolds WJ. Empathy and quality of care. Br J Gen Pract 2002; 52: S9-13 [5] Mercer SW, Maxwell M, Heaney D, Watt GC. The consultation and relational empathy (CARE) measure: development and preliminary validation and reliability of an empathy-based consultation process Measure. Fam Prac 2004; 21: 1-6 [6] Mercer SW, McConnachie A, Maxwell M, Heaney D, Watt GC. Relevance and practical use of the Consultation and Relational Empathy (CARE) Measure in general practice. Fam Prac 2005; 22: 328-334 Stewart Mercer Senior Clinical Research Fellow Section of General Practice and Primary Care, University of Glasgow, Glasgow G12 9LX Scotland, UK Current address: Visiting Professor in Primary Care Research, School of Public Health, Chinese University of Hong Kong Email stewmercer@cuhk.edu.hk Competing interests: None declared
Dignity conserving care and the need to re-humanize healthcare 29 August 2007
Daniel F Munday, Consultant in Palliative Medicine Myton Hospice, Warwick, CV34 6PX Send response to journal: Re: Dignity conserving care and the need to re-humanize healthcare	Chochinov’s framework for dignity conserving care provides a clear and concise method for maintaining one’s own sensitive approach to patients within ‘the time pressured culture of modern health care’. However, whilst he explores the complex context of the personal clinician - patient relationship and communication, he assumes that such a longitudinal relationship exists. Unfortunately, such personal continuity of care can no longer be assumed: a casualty of both the current model of care delivered by a multidisciplinary team, made inevitable by increasingly complex interventions and a health care system in which continuity is fractured by efficiency engineering. Junior doctors in UK hospitals rarely follow a patient through from admission to discharge; consequently patients are ‘cared for’ by numerous anonymous individuals who are often constrained by the need to administer their ‘evidence based’ checklists. Continuity seems to have been reduced to merely ensuring health care information is passed on from one clinician to the next and even that information is often reduced to boxes ticked on a form. These systemic constraints make Chochinov’s framework all the more important. As clinicians we need to redouble our efforts to provide ‘humane’ care within an increasingly dehumanising system. We need to appreciate the effect that lack of personal continuity has on vulnerable patients and try to partially mitigate against this by condensing the fundamental tenets of dignity conserving care into the few pressurised minutes we spend with patients; listening to what they say, rather than hearing only what we can score on our charts. Patients however still both require and value personal continuity from clinicians. Whilst respect for the patient and their dignity should characterise all clinical encounters, in only a few trusting, continuing and supportive clinician-patient relationships will it be appropriate for patients to share their deeper selves (the type of relationship which seems to be assumed in Chochinov’s paper). We need to urgently find ways of rehumanizing the system in which we work. Whilst one trusted doctor delivering care alone to an individual patient belongs to a bygone era and cannot work in the majority of modern health care contexts, personal continuity must be protected and fostered. The ‘key worker’ providing dignity conserving care may be one model for providing such continuity. This concept should be developed with particular attention to how the key worker is selected - ideally it should be the patient who selects - and how she relates to the wider team. Multidisciplinary teams need to explore exactly what this model of working means within their specific domains, taking care to listen to what patients tell them about it. Furthermore the patient’s dignity must be respected within the team setting. Only in this type of Environment can the ABCD of dignity conserving care be fostered. Competing interests: None declared
Patient Dignity - essential reading 6 September 2007
John Wilson, Consultant Physician Fife Acute Hospitals KY2 5AH, John A. Wilson Send response to journal: Re: Patient Dignity - essential reading	I was moved and impressed by Harvey Chochinov's article, and have been sharing it with all my nurses, junior doctors and some consultant colleagues. It is so easy to look on patient contacts as out "daily bread" and to forget the impact our dealings have on individuals. Prof Chochinov reminds us, gently but clearly, of the importance of according each individual their space, their identity along with sufficient time to be heard and listened to. This article goes right to the core of what we should be doing. Competing interests: None declared