Rivista per le Medical Humanities

Liala Cattaneo
rMH 23, 2012, 11-15

History of a burnout

In her capacity as a social management consultant and coordinator of a Laboratory of Psychopathology of  Labour, the author has had many an occasion to meet people suffering because of their jobs. Sometimes, the burden is represented by the work load, the long shifts, poor organisation, conflicts. Other times it is about disillusion, frustration, discouragement, loss of any pleasure to work. If in the former case the use of the term “distress” (or “negative stress”) is adequate, the latter calls for a different term, “burnout”, which stands for those states of psycho-physical breakdown in which people find themselves when the early ideals and illusions crash against the wall of the working-place reality. This is everyday experience for those who chose help or care professions, as for the person whose testimony is here reproduced. The objective is to alert everyone against underestimating the signs of a burnout; to show how getting out of it may be difficult, but not impossible; most of all, to encourage people to seek and maintain a balanced lifestyle, the only guarantee for a healthy and durable career in the socio-medical field. 

Isabelle Gernet
rMH 23, 2012, 16-20

The job of caregiver, between suffering and pleasure

Labour psychodynamics provides a definition of “vital”, subjective work, highlighting the human implications of the working condition. The caregiving professions are aimed at the resolution of difficulties through technical and relational capacities shared within the professional environment thanks to the establishment of forms of co-operation. These jobs, however, command a special acknowledgement (particularly from the outside) in virtue of their “discreet” character. The existing work evaluation standards jeopardise the balance between suffering and pleasure, exposing the caregivers to the risk of chronic dissatisfaction and to the development of burnout syndromes. 

Nicola Grignoli
Valentina Di Bernardo
Tiziana Sala Defilippis
rMH 23, 2012, 21-26

Stress and moral distress in intensive care units

The practice of medicine and nursing care in intensive care units is an extraordinary professional activity, requiring high technical skills as well as stress-management capacities. As shown by the recent literature on the subject, a number of specific factors are correlated to the risk of developing a burnout syndrome by caregivers in intensive care units. Moreover, a number of exceptional situations may cause a state of psychological conflict of an ethical nature, known as “moral distress”. Here we provide a definition of this phenomenon at the border between psychology and ethics, and we point at some strategies to prevent the insurgence of such conflict-scenarios. 

Paola Zanotti
rMH 23, 2012, 27-32

The management of emotions in oncology

In the field of oncology, as in other medical domains, the major motivating factors that lead a subject to opt for a caregiving profession are often put to the test by the relation with the patients (their subjective emotional load, their pain and death). This situation can be worsened by the organisational context of labour, triggering a psychosomatic reaction known as burnout syndrome. Burnout syndrome is described as the cleavage between the personal resources of the caregivers, the needs of the patients and their relatives, and those of the care system in general. This paper describes the clinical features of the burnout syndrome in oncology units and highlights some of the aspects and factors of prevention, in the perspective of the organisation and group, as well as that of the individual. A casestudy is presented, which derives from the author’s personal experience, i.e. a debriefing following the death of a patient in dramatic circumstances, the emotional consequences of which have proven especially trying for the caregivers involved. 

Pasqualina Cavadini
rMH 23, 2012, 33-38

The borders of care, a borderless care

This article aims at making explicit the two poles comprising the caring profession, more specifically the elderly care mostly performed by migrant nurses (the so-called “badanti”). The context is provided by the growing commodification of reproductive labour and the creation of worldwide care-markets. In order to keep the elderly at their home, ever more families need to resort to a form of help that may satisfy the need for long-term daily nursing. A new professional, the live-in nurse, has become a new element in the process of elderly care. But the lesser standing attributed to in-house labour and labourers does not change the fact that it is paid for. The apparent naturalness of the competences required for the job, as well as the superimposition of life space and work space, provide an obstacle to its professionalisation. To the “badanti”, the fulfilment of their mission of caring represents the aim of, and reward for, an unrecognised work. Migrant women channel in the elderly care all the attention and care that are diverted from their dislocated families, in a borderless care labour.

Angelica Lepori Sergi
Christian Marazzi
rMH 23, 2012, 39-43

The health of labour

In recent years the labour market has undergone major transformations, triggered by the transition from a Fordist to a post- Fordist model. At the roots of this new socioeconomic paradigm stands the idea of making workforce and employment conditions ever more flexible. It is a transversal phenomenon involving, in different forms and modalities, all the productive sectors, public and private alike. The analysis of the new forms of labour and of the productive organisation highlights some pathological and disabling factors, touching all the existential dimensions of the subjects. From an element of integration and building of individual and collective identity, labour has become a factor of exclusion and suffering. 

Filippo Bignami
Carlotta Vieceli
Omar Trapletti
Alberto Bonzano
Liala Cattaneo
rMH 23, 2012, 44-49

Understanding labour

The Laboratory of work psychopathology is an initiative of the OSC (Organizzazione sociopsichiatrica cantonale - Sociopsychiatric regional organisation of Cantone Ticino, Switzerland), focusing on the connection between workplaces (and work organisation) and psychological and psychiatric diseases or ailments. This connection is nowadays recognised by a considerable scientific literature as a socio-economic problem, in particular in these years of rapid changes in the working processes and of labour market restraints. The Laboratory has been active since 2006 and has developed its activity first as a structured analysis and reflection upon problematic cases (with an approach through storytelling or videos). It has later grown into a real service where subjects with psycological work-related problems can seek for support and case-management. This article reports features of, and provides information about, the 316 people supporeted by the Laboratory in these years, proposing some markers from different perspectives, e.g. for their education/ training levels, economic status, social status, ailment complained etc. This picture provides a better understanding of the Laboratory target and of the actual impact of the service, as well as an outlook on possible paths to strengthening its activity and to provide a prevention service on the field, for companies, organisations and individuals. 

Graziano Martignoni
rMH 23, 2012, 50-55

Ars curandi and the discovery of one's own daimon

Care springs where the torment and anguish of living are made more intense, where man experiences the vertigo of endless dying. At this very junction, Care is capable of bending destiny in a new direction, to turn the exile into an exodus, nourished by the hope and warmth of the strong tenderness of an encounter, making space for its sunnier facet. In its being generative, Care stands out as a poietic gesture, which has its foundation in the solicitude and pre-occupation towards the Other and the Otherness. Solicitude as love, tenderness, kinship, but also attention, accuracy, conscientiousness, consideration… Preoccupation as apprehension, the condition of être-déjà-là before the encounter takes place. These terms provide a sort of cartography of what Care may be, as well as defining its ethical horizon. 

Paolo M. Geraci
rMH 23, 2012, 79-88

The history of transplant

The first heart transplant by Christiaan Barnard in 1967 South Africa was a real breakthrough. The heart was harvested after the cardiac arrest. This is because in those years the death coincided with heartbeat arrest. Donors were always “Non-heartbeating” (NHBD) individuals. The report of the ad hoc Harvard Committee (1968) introduced the concept of brain death that revolutionised the idea of death. Since then the age of transplants from heart-beating donors (HBD) began to take the place of previous NHBD. The organ shortage that we are experiencing in recent years has restored the “old” donors after cardiac death (DCD). In Maastricht, Gauke Kootstra has pioneered DCD transplantation defining four categories of NHBD, stratified according to the idea of “controlled” or “uncontrolled” donors. Anglo-Saxon countries, United States, Belgium and the Netherlands have worked on “controlled”, whereas Spain and France have concentrated their efforts on “uncontrolled” donors. Several organ-storing techniques have been used, from in situ cooling to hypo- or normothermic extracorporeal circulation. This has been successfully used in Spain and recently also in Italy. Today both procurement programs, after cardiac death and after brain death are carried on in several countries and harvested organs in DCD are beyond kidneys, liver and lungs. 

Ignazio R. Marino
rMH 23, 2012, 89-92

The life/death debate

 A brief summary of the history of organ transplantation, from mythology through the most recent scientific discoveries in the field introduces an international analysis of the data pertaining to the widening gap between the number of patients awaiting organ transplantation and the number of transplants performed and to the reopening of the bioethical debate around the definition of brain death.

Jean-Claude Chevrolet
rMH 23, 2012, 93-97

Cerebral death: an opinable concept?

In the past, life and death were simple issues: life ended when respiration and heartbeats stopped. The person was then declared dead and rituals could begin. In the 1960s, intensive and critical medicines were developed. When a respiratory arrest occurred, mechanical ventilation could be applied, and some patients maintained some degree of cardiac activity and hemodynamic stability, at least for some time. This, together with greatly improved immunosuppressive techniques, allowed the use of organs potentially preserved for transplantation purposes. These patients were denominated “brain death” patients as soon as 1967 (Harvard Committee). This first attempt to define brain death very soon became the focus of multiple controversies. The concept of brain death was attacked with medical, philosophical and societal arguments. In the year 2008, the President of the United States decided to reconsider the question, apparently without any major success. The situation in the year 2011 seems to be the following: either the concept of “brain death”, despite its difficulties, remains acceptable and accepted, or we must delete it. Clearly, if we wish that transplantation activity remains permitted, with this last option, we have to renounce to the “dead donor rule”, an almost sacred concept in our medical world. 

rMH 23, 2012, 98-106

The uncertainties of non-heart-beating organ donation protocols

Non heart beating organ donation protocols (NHBD), currently applied in many Countries with good quantitative and qualitative results, rest upon the “dead donor rule”: patients must be dead before organ retrieval and death must be neither caused nor hastened by the retrieval. Two DCD subsets exist: the uncontrolled protocols (Maastricht class 1 and 2) and the controlled ones (Maastricht class 3). The main problems of uncontrolled DCD protocols are the absence of clear and shared criteria to forgo cardiopulmonary resuscitation and the use of organ preservation procedures before retrieval without valid consent. In controlled DCD protocols, the cardio-respiratory standard for determining the “irreversible cessation of circulatory and respiratory functions” has to be interpreted. The circulatory function should be intended as the mechanical rather than electrical cardiac function. Furthermore, irreversible should be intended as spontaneously irreversible, as no effort should be made to restore circulation after forgoing of futile vital supports. Again, to reduce organ ischemia, the interval between asystole and incision tends to be reduced to two-five minutes. This conclusion raises some problems. These concerns are even more relevant if successful transplantation of a heart retrieved in a NHBD protocol is considered. In this case, perhaps the correct term to define such protocols could be “donation after circulatory arrest” (DCA) rather that donation after cardiac death” (DCD). In conclusion, the definition of donor’s vital status in NHBD protocols is a matter of both scientific facts and values.