So the process of coming to this question has been a little arbitrary, and the title is really as strongly worded as it is to get your attention, but if you stick with me, I hope we can discuss what I think is a hugely important aspect of patient care and informed consent. Non nurses, please don’t look away now! This can apply to anyone who ends up caring or being in charge of the welfare of anyone else.
Unfortunately I have, for the last four weeks, been restricted to being mostly on my back having sustained an impinged cervical nerve. Indeed this is the first time I have managed to crawl to the computer and relatively comfortably sit and type. (And you were hoping my blogging career was over!) The point being that over the last four weeks I have been reading anything and everything; some of it interesting, some of it not, but almost all of it very random. This morning I came across a piece on the internet by the BBC about a group of tourists who were kidnapped and taken hostage on a beach in the Philippines. Naturally the BBC being the guardian it always has been (ahem) it finished off with quoting a psychologists’ check list for survival and things to be aware of after having been kidnapped. It goes as follows:
- Settle into a routine as soon as you can. The tendency for disbelief and anxiety can lead to being jumpy so the need to be calm is paramount.
- Fresh water, food and hygiene will have an all consuming importance when you are deprived of it.
- Fear is the ever present emotion for which nothing can prepare you.
- Try and establish a positive relationship with your captor and draw on the human tendency to be sympathetic.
- Be aware that this might lead to feelings of sympathy for your captors. Something known as Stockholme Syndrome.
Now being a Nurse and someone with a leaning towards satire, I couldn’t help finding my mind translating this checklist onto a checklist for patients. I momentarily thought of writing a spoof patient advice leaflet, but in light of the recent Francis report, I found the idea distasteful. Sadly, in light of the Francis report, it appears that such advice in some areas of the country within the healthcare system, would not even have been satirical.
I was almost happy to leave the matter there. After all, the Francis report has highlighted enough and we are all working hard to ensure that patient neglect and abuse never occurs in our own hospitals; but then my mind suddenly turned to a past patient of mine who, in some respects, had acquired a psychological state not dissimilar to Stockholm Syndrome.
Stockholme Syndrome, as stated already, is a state of mind adopted by a captive in order to cope with the trauma of being held hostage and having their independence and liberty removed suddenly. It entails building a relationship with ones captor; feeling empathy or sympathy for them and even defending them. The most famous extreme is Patty Hearst; heiress to a media tycoon and kidnapped by an urban guerrilla group in San Francisco in the 1970s, she disappeared and ransoms were demanded. Strangely enough, however, some time later she was captured on film, semi automatic rifle in hand robbing a bank with her captors. Lets leave Patty there and go back to Nursing.
Disease and hospitalisation can obscure how somebody looks. Though it is very much a part of someone’s story that altered appearance can in itself, cloud visibility of who that person actually is or indeed the very important stories that came before. The particular patient I have in mind however, had really non of these issues on initial meeting. He was in his eighth decade of life but his comprehension, physical stature and muscular tone betrayed a person who, up until short time before his admission, had been very active. We’ll call him Bill.
Bill, indeed, had enjoyed an active life. Having started life working for hotels at a young age, he joined the Royal Navy where he trained as a Diver. Upon leaving the Navy he took up a career as a rescue diver. It was a career which he loved but also funded an adventurous life style that included climbing some of the most demanding mountains in the world and various demanding treks over the planet. Needless to say, becoming truly ill, incapacitated and being admitted to hospital for the first time as well as being placed in a side room in perhaps one of the busiest wards in the trust, was arguably as traumatic psychologically for him as it would have been if he had been taken hostage.
Now I have a confession. When I take hand over from another nurse, I am always a little cheered up when I hear that certain patients have displayed belligerence and bloody mindedness. I have always been taught that, in trauma situations, the people you initially need to worry about the least are the ones making the loudest and most comprehensible noises. I’ve taken this lesson with me onto the ward where I know that if a patient is particularly bloody minded or belligerent, they have a real sense of self and what they wish to maintain about themselves in a setting which will very often strip them of independence and power. I remember being overjoyed when I heard a 98 year old man, admitted with recurrent falls respond to a physiotherapist offering tips on walking say:
“I’ve been walking for 96 years. I don’t need bloody advice from someone nearly four times younger than me!”
Indeed it is the quiet ones, the compliant ones that, as a nurse, I feel I need to keep an extra eye upon. These are the ones who seem so trusting that they just assume it is normal to handover who they are and what is important to them.
Bill, I initially thought, was going to be one of those who was definite and straight about how he liked things. I thought he might even give me a run for my money but I was surprised. Bill, to date, has been the most compliant patient I have ever come across. It was accompanied by comments such as:
“You know, I once stayed in the Dorchester and lots of other grand hotels, but the food and the care in here tops all of them put together.”
“I really am so lucky to be here being looked after by you and your colleagues. You really are the best nurses.”
Such statements ought to have reassured me that I was doing my job properly. I might add, that I was doing my job properly and had not in anyway kept this patient hostage in any way! But there was something not quite right about the way he said these things. They were constant and somewhat inappropriate to his situation. Sure enough, I like to think he was getting the best care that I could have given him in a department that was well run, but it wasn’t the Dorchester by any stretch. I find it hard to describe why, but there was something about his comments and his almost over compliance with the care he was receiving that made me feel uncomfortable. Something about it all made me feel I was doing him a disservice. Something about it all presented him as possibly one of the most vulnerable patients I have ever come across.
The amount of times I have looked after patients and particularly elderly members have said, “Oh you don’t need to explain everything, just go ahead do what you need to do”. They have also shown a huge, sometimes obsessive interest in the person caring for them. Part of me in the past always put this down to the generation, but coming across it with Bill who, frankl, even in his incapacitated state, could have flattened me with one swipe, led me to think this was something common but unacceptable and wholly sinister with regards implications for anyone who gets admitted to hospital.
I refer back to the previous BBC checklist and ask you as nurses or carers to consider, as an exercise, any patients in your career for whom the above important aspects might have been compromised. It is a sad fact that any admission into the best hospital will sometimes involve a reduction in independence and liberty. The ideal is that this is recognised by both the patient and carer/nurse and is compensated for within the therapeutic relationship. How many of you though, have been overjoyed when you have come across an immensely compliant and sweet patient who will shower you with compliments and let you go about your business, including intimate care, without so much as a demand or minor gripe? Whilst I am sure most people reading this will be great nurses and carers, I would like to stress that such compliments maybe are not always a reflection of the care being given but a reflection of the care the patient wishes to receive. Perhaps they are requesting that care by building a picture albeit submissively and non confrontationally for fear of being harmed.
Some might call this a cynical outlook. I would like to suggest it is a realistic one that recognises the vulnerability of the compliant patient. In fact I hate the word compliance and yet it is used so often as if we, as health care professionals have a right to have the care and treatment we’re offering accepted without complaint or challenge.
Whilst I wouldn’t diagnose such compliance as being wholly tell tale of Stockholm Syndrome, I think it possesses similarities that we should not ignore. In practice then, it has implications as to whether that clexane injection we are giving is really being given with full, informed consent. It has huge implications when someone accepts an incontinence pad whilst they are unable to get to the toilet in time. It creates lasting patterns of practice and behaviour which can, if we’re not careful, eat away at some ones autonomy and self worth inside and outside of hospitals. Worst case scenario is that someone agrees to major invasive treatment not because they know why, but because they’re scared of refusing it.
So whilst I agree that the title of this blog is probably a little strong there are some points I’ve made which I think we need to be mindful of. Compliance and sweet talk does not equate to informed consent or that we are doing a great job. It can equate to abject fear and a reaction to a traumatic separation from liberty. That, in my book, is not consent.
Lastly then, I wonder whether there is a hidden research question here? Do some patients adopt characteristics of Stockholme Syndrome and in what situations? I may be barking up the wrong tree but I hope there are at least a couple of points here that might make people think again before being thankful for that dream, non belligerent patient.