Empathy is the hallmark of every nurse’s practice. It’s the concious act of putting yourself in someone else’s shoes in order to validate the patient’s emotions and thoughts, and to gain insight into their condition. It’s the foundation of therapeutic communication — nurse-speak for talking with your patients in a way that furthers and helps their treatment. Or so we learned in nursing school, along with those other Nursing Virtues such as Active Listening and Compassion. But in practical terms is being empathetic with every patient all the time possible?
I was thinking about this a couple of days ago working in the Resus Room. I had a 20-something patient who was a victim of ovarian cancer, and who presented to the ED with increased pain, nausea and vomiting. She was, frankly, a mess. She was dehydrated. Her port-a-cath had just become non-functional, probably blocked with a clot. She had poor veins, so blood draws and IV insertion was problematic. She had hoped the progress of the disease had been arrested by chemotherapy and radiation. Unfortunately the CT scan showed extensive metastases to the liver and abdominal wall: the cancer had spread beyond all hope of cure. She bore this news stoically, her mother weeping quietly by her bedside.
She had an ileostomy from a previous history of Crohn’s disease; the stoma was inflamed, the seal was poor, and the skin around the site excoriated from the constant leakage of liquid stool.We had to clean her and change her sheets frequently. It was very unpleasant, and the odour was overwhelming. (Nurses are supposed to maintain professional composure at all times — this is pretty well ingrained in all of us from Day One in school — but even the best of us will flinch in the face of certain body fluids.) She bore all of this with calm dignity, and after we bathed her, replaced the stoma appliance, gave her clean linens and made her more comfortable, she thanked us and apologized profusely for the leaking ileostomy.
She was not a difficult patient, clinically speaking. She was, as we say, “lovely.” After we gave our best care, and sent the patient safely to the floor, my partner-of-the-day said to me, “That’s a patient I don’t mind taking care of.” She was talking about empathy, of course.
Which made me wonder: what makes it easier to empathize with some patients, and harder with others? It isn’t just a question of complexity or difficulty or bad smells. In general, I think, patients who are stoic or resigned, and show even the slightest glimmer of gratitude — in short, the most passive in receiving care from us — are the easiest to empathize with. This might just be human nature. Contrariwise, nurses sometimes will speak of “difficult” patients — demanding, blaming, complaining, hostile, manipulative, dramatic, but also those who are strong self-advocates (and, really, how do you tell the difference from the previous?) — and these, to be sure, are often harder to empathize with: it’s hard to walk in the other guy’s shoes if that guy is yelling in your face, right?
Maybe. But I always think, in the back of my mind, when confronted with the demanding, yelling, manipulative, et cetera patients that there’s a reason behind being “difficult” — and there is almost always a reason, whether we think it’s valid or not. I once watched a superb nurse in my workplace defuse the “difficult”, screaming family of an elderly patient who had visited the ED repeatedly, and who was facing a long wait to be seen by a physician. By drilling down, and yes, by showing empathy she ascertained the real issues: the family needed more home care to deal with her increasing debility and they were at a loss at where to start for nursing home placement. Two things, in fact, we could readily fix. The patient and family left happy and grateful that someone had taken the time to really listen to their concerns, and we avoided an unnecessary admission. How many of us would skip the empathy and go straight to slotting the patient as “difficult?”
Being empathetic to the “lovely” patient is easy. And sometimes, I think, a bit patronizing. More challenging for nurses, and perhaps more necessary and important is the “difficult” patient. Yet it’s here we tend to fail.