SOCIAL RELATIONS SOCIAL RELATIONS IN THE IN THE

“HIGH PLACE” OF “HIGH PLACE” OF TECNOLOGYTECNOLOGY

S. TomelleriS. Tomelleri

Bergamo UniversityBergamo University

ItalyItaly

Intensive Care UnitIntensive Care Unit (ICU)(ICU)

• Qualitative research onQualitative research on end-of-life- end-of-life-decisiondecision

• 6 6 ItalianItalian’s ICU (4 North, 1 ’s ICU (4 North, 1 CentreCentre, 1 , 1 SouthSouth))

““HIGH PLACE” OF TECNOLOGYHIGH PLACE” OF TECNOLOGY

Adult Heart Pump Haemo-dialysis machine

Brain death

Starting HypothesisStarting Hypothesis

In the beginning of our research, In the beginning of our research, I was firmly convinced that I was firmly convinced that

care workers engaged in care workers engaged in ICUsICUs were culturally influenced by a were culturally influenced by a

kind of kind of magicmagic and and salvificsalvific ideaidea of their of their professionprofession

End-of-life decisions End-of-life decisions

The end-of-life decisions concern The end-of-life decisions concern more precisely admissions and more precisely admissions and discharges to/from ICUs and the discharges to/from ICUs and the

limitation of intensive treatments. limitation of intensive treatments.

Technical equipments and Technical equipments and human frailty human frailty

Types of patientsTypes of patients

• Critical patients: Critical patients: those who those who experience an acute organ shortage experience an acute organ shortage (70% of total admissions ) (70% of total admissions )

• Monitored patientsMonitored patients: : those who have those who have high possibilities to have high possibilities to have complications that can immediately complications that can immediately cause the risk to life cause the risk to life

Meaningful narratives in Meaningful narratives in the medical practicethe medical practice

Dr. Antonio Porta’s Dr. Antonio Porta’s ghostghost

What about the presence of a sort What about the presence of a sort of GHOST, who is neither the sick of GHOST, who is neither the sick person nor the other human beings person nor the other human beings but a ethereal presence that does but a ethereal presence that does not exist and is able to unplug the not exist and is able to unplug the machine?... machine?...

To be continued…To be continued…

What I would like to say is that we What I would like to say is that we are maybe afraid to act in first are maybe afraid to act in first person. We cannot even claim that person. We cannot even claim that a friend of ours unplug the machine a friend of ours unplug the machine instead of us because this would be instead of us because this would be a way to shift the blame to him. a way to shift the blame to him. However, would be right or wrong, However, would be right or wrong, if there was something – neither us if there was something – neither us nor the patient – that removes our nor the patient – that removes our responsibility to decide?... responsibility to decide?...

To be continued… To be continued…

How would be possible to cope with How would be possible to cope with the problem if there was a third the problem if there was a third person – not us – that is willing to do person – not us – that is willing to do that and is able to intervene in what that and is able to intervene in what we can define as a “aseptic way” we can define as a “aseptic way” without religious, moral scruples and without religious, moral scruples and what have you? What would we do? what have you? What would we do? Would we tell to this third aseptic, Would we tell to this third aseptic, ethereal person: Don’t move! ethereal person: Don’t move! I I mustmust decide!”? decide!”? Or would we leave the Or would we leave the decision to its destiny? This is what I decision to its destiny? This is what I was thinking about. was thinking about.

The EndThe End

Idea of technology Idea of technology

• Third neutral actorThird neutral actor • Universalistic standardizationUniversalistic standardization • Semiotics of the evidence Semiotics of the evidence

(Evidence Based Medicine)(Evidence Based Medicine) • Formal and rational organization of Formal and rational organization of

time and spacetime and space • Quantitative schemasQuantitative schemas

Initial hypothesis was Initial hypothesis was wrongwrong

• One out of six patients dies in Intensive One out of six patients dies in Intensive Care UnitCare Unit

• The narratives of the participants in the The narratives of the participants in the research reveal, indeed, a research reveal, indeed, a disenchanteddisenchanted relation with technology. relation with technology.

• Doctors and nurses highlight the Doctors and nurses highlight the difficult rediscovery of the difficult rediscovery of the social social dimension of treatmentdimension of treatment which can which can not be eliminatednot be eliminated

Dr. Giorgia RizzoDr. Giorgia Rizzo

We can say thus that we are no We can say thus that we are no more concerned with this issue… more concerned with this issue… We should follow the example of We should follow the example of Ponzio Pilatus in order to be Ponzio Pilatus in order to be concerned anymore or, in concerned anymore or, in alternative, we could not escape alternative, we could not escape from being involved in the issue from being involved in the issue (Beta I)(Beta I)

Dr. Paolo LombardiDr. Paolo Lombardi

Or, in alternative, you wait to shift Or, in alternative, you wait to shift change … (Beta I)change … (Beta I)

The crisis of universal The crisis of universal standardization standardization

• A human being is linked to A human being is linked to technical equipment in a kind of technical equipment in a kind of indissoluble way…indissoluble way…

• The medical staff is concerned with The medical staff is concerned with approximationsapproximations and and failuresfailures of of such an equipmentsuch an equipment……

• Always part of organizational Always part of organizational situationssituations

The paradoxThe paradox

The more technology asserts The more technology asserts itself and gets stronger as itself and gets stronger as

therapeutic action, the more therapeutic action, the more this produces new emerging this produces new emerging

relational and social horizonsrelational and social horizons

Rediscovering the Rediscovering the importance of social importance of social

relations relations • The relation with patient’s relatives The relation with patient’s relatives

should be cared more and more;should be cared more and more;• The understanding of the organizational The understanding of the organizational

nature of the treatment;nature of the treatment;• The instrumental acting of expert The instrumental acting of expert

knowledge;knowledge;• A criticism – that can be more or less A criticism – that can be more or less

consciously expressed – to the idea of consciously expressed – to the idea of an omnipotent doctor, who has the an omnipotent doctor, who has the power to save.power to save.

Dr. Mario Colombo’s Dr. Mario Colombo’s storystory

The child was lost by then and these other The child was lost by then and these other doctors started with the usual discourse: doctors started with the usual discourse: “But if…because if…if he rides out this “But if…because if…if he rides out this phase, if he shouldn’t have, if…if…it could phase, if he shouldn’t have, if…if…it could occur that…”. Such a discourse took place occur that…”. Such a discourse took place between a doctor who was there and me. between a doctor who was there and me. There was no wall, but a big window that There was no wall, but a big window that divided us from the corridor where the divided us from the corridor where the child’s parents were standing “outside” in child’s parents were standing “outside” in front of us following the dialogue between front of us following the dialogue between the onco-hematologist and me as they had the onco-hematologist and me as they had followed a tennis match. followed a tennis match.

To be continued…To be continued…

At a certain point my colleague told me: At a certain point my colleague told me: “Beh! I absolutely don’t want to force “Beh! I absolutely don’t want to force through a decision – you know – make a through a decision – you know – make a decision for yourself whether accept the decision for yourself whether accept the child”. I looked at the parents, who had child”. I looked at the parents, who had before moved their heads from side to side, before moved their heads from side to side, but, at that point, kept still on me, looking at but, at that point, kept still on me, looking at me…so I decided to accept the child here (in me…so I decided to accept the child here (in Intensive Care Unit) and he died straight Intensive Care Unit) and he died straight after. And it was my flop, since I told to the after. And it was my flop, since I told to the parents: “Remember that the child come in parents: “Remember that the child come in there – in Intensive Care Unit – but the very there – in Intensive Care Unit – but the very fact to be attached to a life-support system fact to be attached to a life-support system doesn’t give him the chance to survive”. doesn’t give him the chance to survive”.

To be continued…To be continued…

I tried to explain them that the child I tried to explain them that the child didn’t breathe anymore and we didn’t breathe anymore and we wanted to make him die without wanted to make him die without suffering: “We want to send him to suffering: “We want to send him to sleep. This way, he does not suffer sleep. This way, he does not suffer but this phase can last only few but this phase can last only few hours”. In other words, the child hours”. In other words, the child doesn’t come in there to give you doesn’t come in there to give you hope that there still is something to hope that there still is something to do, but he comes in there to die do, but he comes in there to die without pain.”without pain.”

To be continued…To be continued…

By the way, this kind of decisions is By the way, this kind of decisions is also taken according to a certain also taken according to a certain background. I was obliged to do background. I was obliged to do something I was aware it was something I was aware it was wrongful, because the child didn’t wrongful, because the child didn’t suffer since he was in a coma. suffer since he was in a coma. However, there were two parents However, there were two parents staring at me and making me feel staring at me and making me feel the weight of deciding…I was put in the weight of deciding…I was put in a difficult position and I could a difficult position and I could decide in the wrong way only. decide in the wrong way only. (Delta II)(Delta II)

The end

Critical situation Critical situation

• The pressure exercised by the The pressure exercised by the parentsparents

• The instrumental behaviour of the The instrumental behaviour of the colleaguecolleague

• The context of the communicative The context of the communicative interaction (the big window)interaction (the big window)

• The critical conditions of the patient The critical conditions of the patient • The young age of the dying personThe young age of the dying person

Relational nature of the Relational nature of the treatmenttreatment

The specialist division of the The specialist division of the treatment – that makes the patient treatment – that makes the patient get lost in a network of wards, get lost in a network of wards, sections, and units – overdraws the sections, and units – overdraws the relational ambivalence whenever it relational ambivalence whenever it is possible is possible an instrumental use an instrumental use of specialist knowledgeof specialist knowledge. .

Relational nature of the Relational nature of the treatmenttreatment

Although there was no hope to save Although there was no hope to save the patient, Dr. Colombo decided, the patient, Dr. Colombo decided, in the end, to accept the patient in the end, to accept the patient and that’s why he perceives his and that’s why he perceives his choice to be unjust. However, he choice to be unjust. However, he took his decision according to took his decision according to relational parametersrelational parameters that took that took into account the parents’ point of into account the parents’ point of view, acknowledging that technical view, acknowledging that technical knowledge is part of interactive knowledge is part of interactive dynamics dynamics