Nearly 30 years ago I was drawn into the world of palliative care. Its nature and essence spoke to my innate existential world view. I found an approach to caring that held the scientific rigor and understanding of humanity that made perfect sense to me.
The paradigm of care understood that my relationship with
the person/family as well as the health care intervention I delivered was of important
to the family. Indeed, it was usually the quality of the relationship that
stayed in the memory of the bereaved not the complexity of the intervention! It
was WHO I was as well as HOW I did WHAT I did was therapeutic and healing.
I acknowledge that kind, tender care exists in pockets of
all care settings- from homeless hostels, hospitals to hospices. But should I
expect more ‘depth’ of care from those of us who choose to work primarily in
palliative and end of life care?
I am now beginning to question if palliative care nursing
has somehow lost its way, lost its essence and identity. As the ‘science’ of
palliative care nursing has grown exponentially, where has the ‘art of caring’
gone? Has it gone underground through
lack of organisational vision and guidance? Or has it faded on the branch due
to pressures and conflicting priorities of increasing bureaucratisation of
palliative care settings?
Re-imagining palliative care nursing: incorporation of the Asklepian tenets of care
I want to make a plea for the sake our profession but more
especially those we serve; a plea that palliative care nursing refocuses on both
traditions of care that informed Cecily Saunders vision of end of life care:
the well-known Hippocratic and lesser known Asklepian paradigms of care. She
understood the need for science and rigor of informed Hippocratic care. But unlike
many medical colleagues at the time, she also respected the essence of the professionally
marginalised Asklepian Tradition; that is the spirit; the ‘art of care and
caring’ and relationship in which care is delivered.
Modern medicine and health care draw from two main strands
of Greek medicine. The dominant strand emerges from the rational and observable
explanations of health and illness; these ideas stemmed from Greek doctors,
Hippocrates being the most famous.
The Asklepian tradition stemmed from Greeks strong belief in the supernatural and metaphysical aspects of life and is associated with Asclepius, the god of medicine and healing.
I believe that 21st century palliative care
nursing has much to learn from the Asklepian tradition. This approach is necessary
to counterbalance the dominance of the Hippocratic approach; which has even pushed
forward into hospices and the care of people in the last days and hours of life.
The increasing imbalance of the palliative paradigm is to the detriment of care
needed by people in the last phase of life. And I posit leads to confusion and
loss of identity of the nurses drawn like I was to work within the speciality.
Essential elements of an Asklepian Approach to care
Authentic Presence: Frightened,
vulnerable people need more than uniformed robots. The most sophisticated A.I.
creations don’t touch the suffering of a human being.
Authentic Relationships: People are
really touched when we care ABOUT them as well as care FOR them. Our patients
and families need to feel known and loved to enable them to find their own
Engaged and concentrated attention: The
Asklepian moment of concentrated attention, and the quietness that flows,
comes from the nurse’s own humanity not from externally imposed guidelines and
Personal growth for professional purposes: The personhood of the nurse is key. Are Palliative
Care nurses willing to embark on the personal development that would enable
this mode of care? The nurse needs to create some opportunity for inner growth
and reflection to enable themselves to be able to work in this way.
In other words, at key points of care it’s the personhood of
the nurse meeting the personhood of the patient that matters most – be that
walking someone to the toilet, washing their body, setting up a syringe driver
or having an important conversation (I do wish we would stop calling
It would be easy to say that these tenets of care are too
demanding, too difficult on busy chaotic settings; or not ‘professional’ enough
to protect the nurse or gain them esteem in the MDT hierarchy; or even too
‘fluffy’ to be relevant within specialist Palliative care.
And it is true to say, that not all patients desire this
level of intimate interaction.
But many dying people and those close to them need to be met
in this real human to human way; much more than the posh fancy care
environments we professional get so hung up on. Its ‘the face, not the place’
that’s important as I heard from recent research into the needs of homeless
people at the end of their life.
It is to our detriment we have not elevated the essence of
the Asklepian tradition of care.
Have we lacked courage, wisdom or vision leading us to
follow the paradigm shift in palliative medicine that seeks to fragment and
objectify the body and mind?
In face of their mortality our patients and those who love
them, need more than our drug formulas and outcome measures. They need our very essence to be alongside
them in the fullness and richness of the last phase of life as well as the
suffering and terror.
Have nurses got the courage and wisdom to stand up for the dying (which is all of us one day) and support and articulate a concurrent Hippocratic and Asklepian Care Model?
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