Fed up

The incident

“A patient arrived at the hospital, at the oncology ward. He had pancreatic cancer with metastasis and was undergoing treatment with chemotherapy.

The first thing he told me was that he had vomited blood in the past three days. I was surprised, and asked him why he did not go to the hospital the first day this occurred.

He answered that he had no need to anticipate the consultation, which was already set to take place three days after the symptoms appeared. I could not understand why he was not worried and why he did not go to the hospital before. Vomiting blood, especially in his conditions, is a very serious symptom. I then gave him a new treatment and I later learned that he was hospitalised some days later.

I was shocked both by the words and the ‘laissez-faire’ attitude of the patient. My first reaction was to think that he was stupid and lacked respect for himself. But later on, I also felt bad by this first reaction, when I realised that what he did was understandable: I could perceive that he was tired and stressed by the endless medical treatment caused by the cancer. He somehow needed to reject his illness for a while. I understood that he simply could not stand going to the hospital all the time. He was fed up with the illness and the treatments.”

1. Identities of the actors in the situation

The incident involves two people:

The narrator is a female doctor, oncologist, working in a hospital in Naples, Italy.She is 28 years old, an educated doctor and specialised in oncology – therefore used to dealing with death and life-threatening illnesses. She is very focused on health and passionate about her work.

Male middle-aged cancer patient who arrives at the hospital for a consultation appointment with the doctor. He is Italian and has been affected by pancreatic cancer for a long time. He is treated with chemotherapy.

2. Context of the situation

The incident takes place at a public hospital in Naples, Italy in the oncology ward.

The two actors are linked by a doctor-patient relationship. Their concept of the illness differs as they have a different viewpoint on it: on one side, the doctor is used to looking at cancer from a clinical point of view and understands it as an incident that needs to be treated; on the other side, the patient has been suffering for a long time and perceives the cancer as a situation he is forced to be living with and that disrupts his ideal routine and life.

3. Emotional reaction

The doctor was shocked by the patient´s careless attitude to his own serious, in fact deadly, illness:

  • The first emotional reaction is a mixture of astonishment and mild outrage: is the patient a bit stupid that he apparently does not realise the severity of his own illness?
  • The second emotional reaction is a mixture of empathy and compassion: it is understandable that in order for the patient to survive mentally, he may have to ignore and deny his own severe situation, because he is fed up with treatments, hospitals, doctors, etc.

I was shocked both by the words and ‘laissez-faire’ attitude of the patient. My first reaction was to think that he was stupid and lacked respect for himself. But later on, I also felt bad by this first reaction, when I realised that what he did was understandable”.

4. Representations, values, norms, ideas, prejudice: The frame of references of the person who experienced the shock.

1. Professional responsibility and Professional Identity

As we learn, the doctor has very high aspirations and expectations for her professional work and her ability to treat and cure patients on the basis of her professional experience and skills.In a way, the patient in this case deprives the doctor of the possibility to fulfill her own ambitions, because he seeks medical care so late that the doctor may no longer be able to prevent a worsening of the disease and may no longer be able to treat the patient in time. Doctors work with symptoms as they appear, as in this case, it is about a serious or dangerous symptom, the doctor should be inform very soon in order to have the possibility to treat in, always in the best interest of the patient. The urgency of the doctor and of the medical need it is not reflected in the patient’s behaviour. Thus, in order to fulfill her own professional responsibility and ambitions, the doctor would need the patient to pay attention to his symptoms long before his regular appointments at the hospital.

2. Respect of the patient physical integrity and choice.

In this case, the most important value for the narrator is the ability to provide professional healthcare and cure of patients. However, the value also reflects itself in the professional respect of patients´ bodily integrity and right to decide over their own bodies.

The first value was violated by the patient´s indifference to own severe symptoms. This reaction left the doctor without any possibility to exercise her professionalism in a satisfactory manner.

Likewise, the other value was, at first glance, also violated, since the doctor also expects patients to take proper care of their symptoms by seeking medical help as soon as possible.

However, by second thought, the doctor realised that the patient had another perspective: he was completely exhausted by the many treatments and needed to have peace, mentally and physically. Thus, the doctor realised that the patient was within his rights to decide over his own body. In the situation, he needed the doctor´s full respect and recognition of his bodily integrity.

3. Professional timing in healthcare and treatment in urgent situations:

Linked to the other values, we also meet a value of professional timing. The doctor’s conception of time and urgency is automatically linked to the level of severity of the disease and bodily symptoms. It is a rather professional point of view, related to the medical knowledge of the course and development of the disease. Thus, the doctor also expects patients, especially patients in the oncology department, to react from a similar time conception and a similar concept of emergency in order to avoid further complications in a life-threatening situation.

5. What image emerges from the analysis of point 4 for the other group (neutral slightly negative, very negative, "stigmatized", positive, very positive, real, unreal) etc?

The doctor has conflicting perceptions and images of the patient:

  • On the one hand, the patient seems careless in the way he ignores serious signs of disease. The patient´s reaction – or lack of reaction on severe bodily symptoms seems almost surreal to the doctor.
  • On the other hand, the patient is mature, because he dares to take responsibility for his own life and find a way to handle severe illness in the daily life. Thus, by second thought, the doctor´s image of the patients changes to be much more positive and actually quite realistic.
6. Representations, values, norms, prejudice: The frame of references of the person or group that is causing the shock / that caused the shock in the narrator.

1. Need of being in control of his own lifeand choices

The person who caused the shock is probably tired of his illness. It looks like his patience and perhaps his faith to be cured is running out. The hypothesis about his values in the present situation may be that he is giving priority to everyday life and trying to enjoy as much as he can despite severe illness and symptoms. This may include the rejection or at least postponement of hospital treatment. He respects the regular medical appointments, but avoids, as far as, possible additional hospital appointments and perhaps even hospitalisation. Thus, from a medical point of view, he may seem irresponsible about his health. But from a wider human perspective, he is taking responsibility for his own life and death. We can also think that he needs this autonomy to empower his everyday life.

2. Identity threat

The patient might also be confronted to an identity threat as he might not want to be only recognised as a sick person but also as a man. His ‘patient’ identity might have taken over him and this choice can be supported by the fact of reaffirming his identity as an able person.

Time and urgency conceptions:

At the same time, another hypothesis may be that he is not aware of the severity of his recent symptoms. It may be his conception of time and urgency that waiting a few days more in order to describe his new symptoms in the regular hospital consultation would not change anything in terms of treatment.

The concept of time and urgency in this sense differs from that of the professional, as does the concept of the illness.

7. Does the situation highlight any problem concerning the professional practice, or in general about the respect of cultural differences in intercultural situations?

In incidents like this, it is relevant and important to speak about different conceptions of health, time, cure, urgency of treatment as well as bodily integrity – according to either a professional-medical perspective or a layman and patient perspective. Thus, the incident represents a moment where two people have reacted differently on certain symptoms of a disease and consequently, different levels of concern and perception of the severity and urgency.

In fact it is possible that a doctor has a very different and more complete vision of the health than a patient, who is likely to be less informed and less aware of the consequences of disregarding a severe symptom. Therefore the situation also highlights the issue of professional communication and ways to communicate clearly about threats and consequences for health and life without losing the emphatic approach and the respect for patients´ bodily integrity.

It is possible that the patient would have reacted differently to the symptoms if he had been more aware of the severity they may represent, as his understanding of the disease would have been more aligned to that of the professional. At the same time, this raises the question of how far doctors should go in treatment and treatment decisions that may exceed the patient’s dignity, self-determination and integrity both on a mental and bodily level.  To which point should treatments be forced upon a patient? Where is the threshold between human dignity and medical treatment of a disease?