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Comfort may be the most important thing that physicians can provide

A hospital can be full of discomfort. My patients tell me that the food is


unappetizing. The beds hurt their backs. The noise echoing through the hallways
at night makes it impossible to sleep. And for those patients near the end of life,
the treatments being offered may no longer be of benefit, causing more pain than
good.
The answer to discomfort for those who are very ill is comfort care, the use of
palliation when life-advancing measures are no longer indicated or desired.
These measures include things like giving morphine to dull the pain and ease the
breath, applying lip balm over cracked skin, offering ice chips to revive the
mouth, adjusting blankets or fans, deciding not to press on someones chest, to
stifle their airways with tubes, if their status declines. The decision to turn to
comfort care often means that a patient can receive a private room in the hospital
for family to stay close, to feel sunlight through a window. The triumph of
comfort over the many indignities of being away from home.
Death does not need to happen in a hospital, yet too often it happens here. In
January, I saw two people die. One was old. He had lived a full life; his room was
decorated with photographs from his youth, his tall form in a service uniform, or
in a tuxedo on his wedding night, half-cropped face suspended in a laugh.
When I met him, he was on a morphine drip, no longer able to speak. To gauge
the adequacy of his pain control, we looked at his heart rate, his blood pressure,
scouring for signs of bodily agony. He was tucked into a warming blanket, yellow
hospital socks on his feet. Every morning we circled around him, whispering
hello into the room where he slept, taking stock of the fluorescent etches of the
vital signs monitor, the coolness of his legs.
When he passed, we pronounced him after checking for a pulse and listening for
a heartbeat. I felt solemn, but also grateful for his smooth passage.
The second person I saw die was young. She had been full of life and her death
ripped up all those who loved her. As she became more ill, and more confused,
her family made the brave decision to transition to comfort care. There was
nothing gratifying about it, her loss was unspeakable. But perhaps the final
moments, free from the blinking of machines, the infusion of drugs that upset her
bowels and irritated her veins, carried a dim current of peace.
Not long ago, I lost my grandmother. Towards the end, she had lost control of
many functions of her body, and things that previously gave her joy, like biting
into a chocolate bar or wearing a freshly pressed sari, no longer seemed to matter.
My grandmother grew up during a famine in Bengal. She was strong and
dedicated her life to her family. She knew no dreams beyond the balcony of her
sixth-floor apartment where the laundry flapped like the wings of a crow. She

succumbed early to diabetes, and later dementia. As my grandmother grew


sicker, my family in India made the difficult decision to not take her to the
hospital.
Her two daughters traveled to join their brother and enjoy her last few hours.
Everyone crowded on her teakwood bed where her frail body lay, the same bed
shed slept in since she married my grandfather and moved to Kolkata decades
ago. My mother sang old Tagore songs, her sisters held hands. My grandmothers
toenails were painted red. An ayah gently pushed stray hairs away from her
forehead. Relatives whispered loving words and memories into her ear, knowing
that even if language was lost on her, feeling was not. Then, when her breathing
changed, when its stuttering rhythm finally came to a halt, my family gave her a
final sip of water and pressed her eyelids shut. Not an easy death, not a death
whose pain can be erased. But a comfortable death.
These days on the medicine ward, I often see my grandmothers face. In a sweet
old patient with dementia, who confabulates the most whimsical stories about
why she tripped, fell, and came into the hospital. In a homeless man who keeps
asking for more trays of food. Or in a grouchy woman whose body has been
ravaged by an incurable cancer, who is convinced that the world is against her.
And I have the urge to give her a sip of water. To sit with him. To comb her
tangled hair.
Comfort may be the most important thing that physicians can provide through a
difficult time or at the end of life. When there is nothing else, or when the other
offerings of medicine hurt too much or act too slow, in that moment in any
moment we always have something to give.

The Medical Model vs. The Nursing Model


THE MEDICAL MODEL VS. THE NURSING MODEL
It was none other than Florence Nightingale (1859) who thought medicine and
nursing should be differentiated from one another. Even in the 1970's, physicians
were still lecturing nurses about nursing. Strikingly, BSAVA Congress reported
veterinary surgeons lecturing nurses about nursing in 2005! In 1985, Stockwell
defined a "model" as a "simplified way of organising a complex phenomenon."
The medical and nursing models are some of the most widely talked about topics
in PA, NP, and medical interviews. However, it is up to the student to do much of
the research about these topics and truly understand their profession and the
basis behind the practice they are about to commence. Although difficult to
understand and convoluted, the medical and nursing models are strikingly
unalike in the most basic ways. I hope this article brings light to just that for you
and that you may begin to see the true differences.
The Medical Model (PA and MD/DO)
Medical and PA schools both follow a disease-model that appears to be well
illustrated with more pathology, clinical medicine, pharmacology,
pathophysiology, differential, treatment, etc. Specifically, it emphasizes
anatomical, physiological and biochemical malfunction as the causes of ill health
and by doing so encourages a disease -oriented approach to the patient. The
medical model treats the human body as a "complex set of anatomical parts and
physiological systems," if you will (Aggleton & Chalmers, 2000). The content of
many PA programs also focuses on caring for patients across their entire life
span and is designed to prepare PAs for practice in multiple care settings primary care, emergency/acute care, the operating room, inpatient and outpatient
settings.
The medical model is believed to be derived out of diagnosis of a psychiatric
patient with a mental illness who was given a clinical diagnosis based on
behavior, rather than physical pathology. The medical model followed a workflow
of diagnosis and then diagnostic examination and ancillary testing. Stipulations
on the derivations of the medical model are ongoing.
The medical model does not account for much of lifestyle-teaching or cultural
considerations like the nursing model. Instead, it is an evidence-based
approach to the treatment of diagnoses, based upon the gathering of a history
and physical alone.
The Nursing Model (NP)
The nursing model focuses on patients mental, emotional, and physical needs
and could be expressed as immediate care leading into long term effects. "It is a
mental or diagrammatic representation of care, which is systematically
constructed, and which assists practitioners in organising their thinking about
what they do, and in the transfer of their thinking into practice for the benefit of

the patient and the profession (McKenna, 1994)". Essentially, the nursing model
accounts for the whole patient, not just the disease or condition requiring
treatment. It allows nurses to deliver care to patients using a systematic
approach of assessing, planning, implementing and evaluating patient care - this
is a cyclic nursing process with detailed guidance for each step of care.
Nurses believed that the medical model was not a focus of their discipline, but
with the advent of university educated nurses and the quest for professional
recognition, the nursing model evolved. Nursing is sometimes called "holistic
practice" or "integrative medicine" and this could be because NPs often take
courses in therapeutic communication.This type of medicine focuses on health
and wellness of the overall patient rather than treating the disease itself and
focusing on the patient-physician relationship. NP programs are grounded in the
nursing model and help students master competencies required for the care of
multiple populations (adults, children, and families).
Nurses (RNs) come from a background of care plans where they associate
nursing assessments for their patients, but not medical diagnoses. Detailed
assessments are necessary to establish the individuality of the patient. Planning
is done to prevent recurrence of treated problems. Goals are set so that
evaluation can be measured or tested. Plans are made for intervention to
achieve goals. Evaluation is done to analyze whether improvement was made.
Once complete, effective care is believed to be given. However, this is a nursing
process, incomplete without a scientific foundation or a systematic construction.
The nursing model itself has a different structure. Roper, Logan, and Tierney
(2000) describe the five parts of the nursing model as:
Activities of Living (communication, breathing, eating & drinking, elimination, etc.)
The Patients Life Span
Dependence-Independence Continuum (parts of life when pt. cannot perform
activities of living independently)
Factors Influencing the Activities of Living (Biological, Psychological,
Sociocultural, Environmental, Politico-economic)
Ex. NP must be aware of psychological stressors on Activities of Living and
impacts on patient. Patient suffering from anxiety may withdraw from
communication, refuse to eat and drink and be unable to sleep.
Individuality in Living (Each patient may do them differently, expressing
themselves as an individual)
A PA, physician, and NP work side by side and do the same things in the same
ways. Most can perform line removals, manage medications, perform H&Ps, etc.
Although there are differences, there is also lots of crossover in both models. It is
crucial that you realize there are good and bad physicians, PAs and NPs all
around and it is important to recognize that we cannot pinpoint one poor
practitioners mistakes on an entire group of providers. Even though we may be
trained in different models, come from various backgrounds, have unequal

amounts of experience, etc. we are all responsible for the same patients and the
same goals. We work as a team to ensure patient safety and life longevity.

Making the choice between nursing and medicine


Over the last month I have received several comments from readers who have or
who are trying to make the choice between nursing and medicine. And may I just
say what a great problem we have now, to be able to choose. Ive been thinking
about this and I submit there are three considerations: philosophical, practical,
and logistical.
1. Philosophical. Many of you have heard of the medical model, the idea that
doctors are trained to diagnose and treat disease. Fewer are aware of the various
nursing theories, developed by nurses to try to describe the philosophical
underpinnings of nursing and attempt to define its boundaries.
For example, Dorothea Orem developed the self-care deficit nursing theory,
based on the idea that all patients wish to care for themselves and it is the job of
nurses to restore them to this independence. Roper-Logan-Tierney theory holds
a similar view, that disease is defined by disruptions in patients ability to
perform activities of daily living. Theres a bunch of others along the same lines.
Some of the theory is, frankly, ridiculous verbiage. But it serves the purpose when
you are trying to define differences between nurses and doctors. At least as it was
in the 1980s, the last time a big general theory was put forward.
Heres an example of nursing theory versus the medical model. Say you have a
65-year-old man who has been diagnosed with congestive heart failure. The
medical model knows that this means the left ventricle of his heart is weak and
doesnt push blood forward into the body so that blood backs up into the lungs
causing fluid to accumulate and producing difficulty breathing. If you give drugs
to make the heart stronger or decrease the blood volume, the person gets better.
The heart is the problem. In nursing theory, the patient has congestive heart
failure but the real problem is he cant breathe, cant climb stairs like he used to,
doesnt have the stamina he used to have, etc. In other words, his normal
functioning in life is disrupted. You have to give the drugs but you also have to
address the social, psychological, and educational issues that arise whenever a
person cant do what theyve always done. The disease is the same, the focus of
treatment is different. I will say the medical/nursing lines have blurred: a good
nurse knows her medicine and a good doctor treats the whole person. You get the
idea.
2. Practical. Of course in practice, all the gobbledygook above goes out the
window. Lets face it. Most doctors and nurses these days do mostly paperwork.
Neither gets to take care of people the way they want to. Doctors only get to
spend a few minutes with each patient. All the actual care is done by other
people. If you really want to take care of people, nurses arguably spend much
more time actually laying hands on people and helping them in a physical way.
Most doctors do feel they are caring for patients, but it takes a different form.

Doctors tend to work longer hours and take more night and weekend call, but
nurses are starting to take call also.
The thing about nursing is that nurses have a great deal of responsibility and not
a whole lot of power. A nurses job is not just to take orders but someone does
have to do that and nurses do carry out the orders of doctors, and nurses work
can require a fair amount of physical labor. But as the person who sees the
patient the most, nurses also observe and report problems or complications that
arise, and are usually the first to notice when something is not right. The nurse
might have to seek and order for the thing she knows the patient needs, but
she/he is the patients first line of defense. This advocacy is, in my opinion, the
most important thing a nurse does. A good nurse sees what her patient needs
and makes sure it happens. Again the lines are blurring, as more nurses have
prescriptive authority and do more of the diagnosis.
3. Logistical. Heres the kicker. The barrier to entry in medicine is extremely
high. There are so many hoops to jump through, so many meaningless math
classes to ace, so many standardized tests, that some people who would make
great doctors get weeded out. It will take you 8 to 12 years to become a practicing
physician. The money, time, and hoop-jumping might not be worth it. You dont
need to be exceptionally smart, you just have to be very persistent. Nursing is an
easier way to go educationally, but your knowledge base of medicine will be more
limited, and you will be working under more supervision. A nurse can go on to
get graduate degrees that allow a greater scope of practice, but the educational
process is not as complete or as uniform.
Either way you choose, be very sure it is what you really want to do. Both fields
are demanding and rewarding and take a great deal of commitment.
Shirie Leng, a former nurse, is an anesthesiologist who blogs at medicine
for real.

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