My first experience of death happened when I was working on a hospital ward. I was devastated. We had bonded over a very lengthy hospital stay; while I made sure their room was clean and supported their nutrition, we shared several conversations about death and the future which were difficult, but important. I think such conversations are an important part of what a ‘good death’ looks like. As someone training to be a psychologist I want to work in a way that puts my patient at the centre of my work. I want them to have a ‘good death’. Nonetheless, I couldn’t help wishing there was a rule book on what my responses should be, though in hindsight the four-letter word that came out of my mouth when I was told ‘I’m dying’ definitely wouldn’t make it in that book. I later concluded that there probably isn’t a ‘right’ set of words to say, it’s just being there and listening that matters.
I started working on an Intensive Care Unit in 2018. In an intensive care unit people are generally quite vulnerable and tend to have one-to-one care from nursing staff. At first the Intensive Care Unit can be overwhelming – especially during the winter where people tend to be very ill and we have less beds – but it becomes normal eventually. My work there made me realised that I may need find my own way of coping with death. What I needed was a way to cope with death without distancing myself from my patients as a means to protect myself. Compassion is an important part of patient care and just like the NHS, it should be from cradle to grave.
I work on the unit alongside being a postgraduate researcher. My research is concerned with mental health, and I’ve been aware of the effect of the overwhelming experiences of death on my own wellbeing. I am aware, however, that despite treating every individual like you would want your own family to be treated, over time I’ve found that names and faces become disconnected in my mind when I am told someone I have looked after for many years has passed away. Initially I felt quite bad about this, though I have come to believe that it’s my brain’s way of defending from a kind of grief that would stop me making really strong relationships with people I care for. Despite this, hearing the voices of your patients still remains important and it is possible to manage your own health whilst managing that of others.
Hearing others and communicating
The David ‘Rocky’ Bennett enquiry has long represented an important lesson in how everyone in the NHS can do better, particularly within mental health services. If you haven’t read about David, then I recommend that you do, even if you aren’t working in mental health services. In short, in some instances where a person is in distress and as such they are deemed to be at risk to themselves, they may be physically restrained. This is an action which should not be taken lightly – it represents the very limits of taking away a person’s liberties. This is why the NHS guidelines suggest such action should always be proportional and justified. The same guidelines apply to an instance where you may need to protect yourself – if someone shouts at you, hurling a drip stand is neither justified, nor is it proportional.
In the case of David, following an altercation with another service user which involved him being the victim of racist abuse, David was moved away from the unit. David asked why this was, why it was him who had to move, but his question went unanswered. Following a later altercation with a member of staff, David was physically restrained, face down by 4 staff members for 25 minutes. David died while being restrained from positional asphyxiation.
When I began training for a nursing assistant role on a mental health unit, the role of de-escelation was very heavily emphasised. De-escalation is essentially a type of conflict resolution that is used to avoid a violent situation, this might include non-verbal communication such as maintaing a non-threatening posture or verbal communication such as acknowledging and validating feelings or offering a set of choices or alternatives to the current behaviour rather than say, arguing or ordering a person to do something. For example, “I understand, shall I make us a cup of tea/ do you fancy a walk?” is distinctly different to “go to your room and calm down”.
De-escalation can also be applied in situations where restraint might not typically happen. For example, when I worked on a renal transplant ward, in-patients were not allowed salt and potassium – sometimes they might only be allowed half a litre of water a day. These are very basic things that are part of everyday life at home as well as meal-times and visits from family and friends that can be taken away and understandably it might cause some frustration. There is a distinct difference between telling someone they ‘just can’t or ‘just have to’ and fully explaining why. Nobody particularly likes being in hospital and empathy can go a long way.
Ultimately, the most important part of patient care from psychologists is listening and hearing. Good communication is key to patient care. Hearing what people say is important for identifying and considering important factors including everything from identifying safeguarding concerns and abuse, religious, spiritual and cultural beliefs, dietary requirements and preferences about end of life. The list is not exhaustive but does demonstrate how such communication is something patients want and need, which means it is ultimately good for their emotional health, whether within recovery or towards the end of life. It might seem strange that listening and hearing are the most important parts of communication, given that this requires NHS staff to be relatively mute, but it is its simplicity that makes it so fundamental – if we are listening, then we are hearing, and then if we are hearing, we are truly being patient-centered.
Becky Scott is a PhD student at Huddersfield University. She is the PsyPAG Information Officer, and has recently been published in The Psychologist Magazine for her writing on What Do We Need in Psychology?