Review of article "Eight reasons why doctors fear the elderly, chronic illness, and death" in The Journal for Transpersonal Psychology.
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- © 2008/2014 by Dawn Drake 1 A Critical Review of Lieff, J. (1982). Eight reasons why doctors fear the elderly, chronic illness, and death. The Journal of Transpersonal Psychology, 14(1), 47-60. Literature Review Jonathan Lieff, author of this article, holds a B.A. from Yale College and an M.D. from Harvard Medical College, and is board certified by the American Board of Psychiatry (Ages Health Services Inc., 1996). When the article was published in 1982, Lieff had developed services for elderly, handicapped, and terminally ill patients in connection with the Boston Housing Authority, nursing homes, and hospitals. He had also served as Director of Geriatric Fellowship at Boston University and Chief of Geriatrics at Lemuel Shattuck Hospital, a Tufts University Facility. In this paper, I summarize the article and offer comments about selected aspects, identify some relevant changes that have occurred since the article was published, and suggest areas where additional research findings would assist in understanding the current state of medical care in regard to the issues raised. Article Summary Lieff (1982) described recent (at the time of publication) research findings that indicated “widespread and well-documented prejudice” (p. 47) against elderly and terminally ill patients, and that suggested prejudice and avoidance behaviors were fostered in American medical schools. He also documented benefits of psychological support for dying patients and then identified and discussed eight
- © 2008/2014 by Dawn Drake 2 reasons to explain the fear that he believed could explain doctors’ behaviors toward these patients. Many of his explanations reflected spiritually related problems that he believed were at the root of the issue. Lieff (1982) did note that some medical professionals, mostly not physicians (i.e., nurses, social workers, therapists, and some physicians who find personal reward in providing elder-care), countered the norm by providing more effective services to the elderly. After discussing the relevance of the spiritual needs of the dying, Lieff (1982) concluded by positing the need for an increased professional emphasis on the “psychological and spiritual considerations” (p. 59) of the final stage of life. Critical Reflections The dominant purpose of this article seems to be to convince the reader that Western doctors (specifically, American doctors) were not prepared to support the emotional and spiritual needs of the patients who were dying, and further, that spiritual training should be included as a standard component of medical training for doctors. All of the reasons for fear that Lieff (1982) discussed reflected psychological or spiritual issues; consideration of other contributing factors was noticeably lacking. Although Lieff (1982) offered persuasive ideas to explain why doctors might fear chronically ill and terminal patients, many of his descriptions of doctors’ attitudes and experiences included neither research references nor acknowledgement that the statements were his opinions—presumably based on his experiences in the profession, but opinions, nonetheless. Examples include assertions (Lieff, 1982) that many doctors did not recognize the human potential to
- © 2008/2014 by Dawn Drake 3 transcend physical limitations and find personal fulfillment, that doctors lacked resources for finding “information about the purpose of the ending of life, and of death” (p. 55), that most doctors were not prepared to deal with the impact that religious beliefs or experiences had on the efficacy of medical treatment, and that our society had given doctors “a kind of priestly status” (p. 58). Acknowledging his comments as opinions or personal observations and then explaining his reasoning could have provided an opportunity to persuade a skeptical reader to agreement. By offering neither research findings nor personal reasoning, Lieff potentially increased the reader's resistance to his arguments. Numerous statements also seem to express Lieff's (1982) own frustration in coming to terms with death and dying, especially within American society. For example, Patients and their families generally turn to the physician for solutions to these problems, . . . The typical doctor is perhaps no better prepared to take care of his own elderly parents and grandparents . . . But they are expected magically to provide solutions (p. 55). Theorists, such as Erikson (1963) and Lidz (1976), attempt to include the termination of life as a psychological developmental stage. But what psychological development leads to death? (p. 56) In a medical system that lacks a spiritual basis for making decisions, it is not acceptable to die without a medical cause. This is just one of many ways in which the doctor is rendered helpless in a system which is structured to help him hide these feelings of helplessness (p. 58). Upon recognizing this undertone of personal frustration, the reader might question the objectivity, and therefore the validity, of the overall argument. This, in conjunction with the lack of support for many of the assertions made, undermines the potential benefit of Lieff's (1982) presentation of the issues.
- © 2008/2014 by Dawn Drake 4 Further Research Lieff (1982) supported Kastenbum’s recommendations for providing patient- oriented standards, but expressed reservations about the whether those recommendations could be successfully implemented in America. Lieff (1982) suggested that hospices, which were rare in the U.S. in 1982—only about 1,500 programs existed by 1985 (National Hospice and Palliative Care Organization, n.d.)—might provide a satisfactory model for end-of-life care. Changes have occurred in American society that have dramatically altered the circumstances that existed when Lieff (1982) wrote this article. Some pivotal ones that directly affected medical care are • in 1983, Medicare began paying for hospice care for eligible patients (von Guten & Ferris, 2002), • in 1997, Geriatric Psychiatry was approved as an official subspecialty (American Board of Psychiatry and Neurology, Inc., n.d.), • in 2006, the subspecialty of Hospice and Palliative Medicine (HPM) was approved (American Board of Medical Specialties, 2006; palliative care provides treatment to alleviate pain and symptoms without treating the underlying cause), and • according to the National Hospice and Palliative Care Organization (2007), in 2006 the number of hospice programs in the U.S. had grown to 4,500, serving an estimated 1.3 million patients, and more than one third of all deaths in the United States that year occurred in a hospice program.
- © 2008/2014 by Dawn Drake 5 These changes suggest that a significant shift has occurred, or is occurring, in the way the medical community views elderly and terminally ill patients, but they don’t tell us the source or reason for the change. The research cited by Lieff (1982) needs to be revalidated, especially in regard to whether prejudicial attitudes and avoidance behaviors are still demonstrated in medical schools and among practicing physicians, and what psychiatric treatment is provided to elderly and terminally ill patients. It would also be appropriate to look for other factors besides the fear that might contribute to those attitudes and behaviors. Lieff’s (1982) comments also raised several other issues that suggest further research opportunities. He noted that nurses, social workers, and therapists were leading the way in providing better care for the elderly. How do their ways of treating and interacting with patients differ from physicians? Do they have different attitudes about patients or perspectives on life and death? What is the source of any differences? If they learned the methods and attitudes in a formal setting, how were those alternatives taught? Are those methods transferable to physician training, and if so, has there been progress in incorporating those changes into medical schools? How do patients and their families perceive the care that the nurses and other care providers deliver in contrast to the care that is provided by physicians? Do these patients and their families communicate their feelings to others, and if so, has it effected any change in expectations in those others? How do doctors respond to these methods—are they supportive, obstructive, or neutral? What consequences do these practioners experience, and how does that affect their
- © 2008/2014 by Dawn Drake 6 motivation to continue with their methods? And, of course, how many physicians are entering the new subspecialties that are targeted to treating these patients? Lieff (1982) suggested that physicians should receive more spiritual training, based on his assessment of their fears. It would be appropriate to conduct current research to determine whether his assessments are correct in regard to today’s physicians; for example, whether doctors believe that they have a “priestly status” (Lieff, 1982, p. 58) in our society and that they are ill prepared ethically and morally “beyond obeisance to academic and guild organizations” (p. 58), whether death certificate requirements make them feel helpless, and whether they refer patients to specialists for assistance in coping with “problems of meaning and purpose” (p. 54). Research into doctors’ opinions about including spiritual orientation in medical training would be important, and if they support the idea, what methods they would consider acceptable for determining the content and delivery of that training. This article raises issues and possibilities that are rife with questions worthy of exploration. Additional examination should quickly raise research possibilities beyond those suggested above. Conclusion Lieff (1982) presented convincing research that chronically ill and terminal patients need psychological support, yet many American doctors exhibited avoidance behaviors toward them in the early 1980s. It appears, though, that Lieff’s primary goal was to persuade the reader that spiritual training should be included in American medical training. Because he focused primarily on spiritual issues,
- © 2008/2014 by Dawn Drake 7 positioned opinions as facts, and conveyed an undercurrent of frustration, the article is subject to being discounted as fallacious rather than being accepted as an objective, scholarly treatment of a legitimate professional concern. More than a quarter of a century has passed since the article was published, and in that time, significant changes have occurred in the medical field that affect how terminally ill patients are treated in the U.S. Given the growing population of the elderly and the seriousness of the concerns raised by Lieff (1982), current research into medical training practices and the need and appropriate goals for including spiritual training in medical education curricula seems both appropriate and important to ensuring that a high quality of compassionate and effective care will be available to individuals who are reaching the end of their life.
- © 2008/2014 by Dawn Drake 8 References Ages Health Services Inc. (1996). Form 10-KSB/A-1 Annual Report Pursuant to Section 13 or 15(d) of the Securities Exchange Act of 1934. Retrieved from http://www.secinfo.com—drP9x.81v.htm American Board of Medical Specialties. (2006). News release: ABMS establishes specialty certificate in hospice and palliative medicine. Retrieved April 30, 2008, from http://www.nhpco.org/i4a/pages/index.cfm?pageid=5072 American Board of Psychiatry and Neurology, Inc. (n.d.). Initial Certification in the Subspecialty of Geriatric Psychiatry. Retrieved from http://www.abpn.com/gp.htm National Hospice and Palliative Care Organization (NHPCO). (n.d.). Growth in U.S. hospice programs: 1974 to 2006. Retrieved from http://www.nhpco.org/files/public/Statistics_Research/NHPCO_facts-and- figures_Nov2007.pdf National Hospice and Palliative Care Organization (NHPCO). (2007). NHPCO facts and figures: Hospice care in America. Retrieved from http://www.nhpco.org/files/public/Statistics_Research/NHPCO_facts-and- figures_Nov2007.pdf von Gunten, C. F., & Ferris, F. D. (2002). CAPC manual: Everything you wanted to know about establishing a palliative care program but were afraid to ask. Retrieved from http://220.127.116.11/educate/content/rationale/ushospicegrowth.html