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Life-Support Technology, Enframing, and Disclosing

2005; American Association of Critical-Care Nurses; Volume: 14; Issue: 6 Linguagem: Inglês

10.4037/ajcc2005.14.6.551

1937-710X

Lisa Day,

Ethics in medical practice

The technology available in critical care units is undeniably powerful in its ability to sustain life and restore health. Thanks to the development of life-support technology and the concentration of this technology in critical care units, healthcare providers are able to help more people who are far along in the progression of life-threatening diseases. Understandably, these advances in technology offering the possibility of effective treatment to more people have created a greater demand for critical care services, and therefore the need for critical care beds is increasing at a seemingly unstoppable pace.The technological power of critical care makes it difficult to navigate the boundaries of possibility. It is still common for quandaries to develop regarding when life support should be limited or withdrawn. The patient’s family wants everything possible done and does not want to be perceived as “giving up” on their loved one, and the patient’s wishes often are unclear. When should life-sustaining treatment be defined as inappropriate?In this discussion of the use of technology to sustain life, I suggest 2 ways healthcare providers in critical care settings can use technology and how these approaches might affect relationships among critical care practitioners, patients, and families. Technology can be taken up as a device that enframes and, as part of practice, sets up a disclosive space.1–5 Enframing and disclosing are both concepts described by Heidegger1,2 and more recently discussed by Borgmann,4 Malpas,5 and Taylor.6 I argue that taking up technology as a way of enframing ultimately results in conflict that can be avoided or resolved by cultivating a practice that includes the use of technology but that sets up a disclosive space.In a discussion of technology and its relationship to modern culture, Borgmann4 describes the technological device paradigm as a dominant way of understanding the world. In this understanding, the device is a hidden means to an end and a way to achieve a desired end without being involved in the means. Borgmann uses the example of central heating to illustrate the characteristics of a device. When I use central heating to heat my home, I have little understanding of how the heat is produced. I am cold, I flip a switch, heat materializes, and I am less cold. Heat is a commodity made available by the device, and my concern is related to the commodity and not how it is produced. The expectation is that technology, in its “patterned pervasiveness,” will predictably and consistently produce the same commodity. Technology is established as a way of enframing when the predictability and pervasiveness of the device allows it to become the primary way we control our relationship to nature and to the world. Everything we do becomes necessarily mediated by the technologic device, and the device paradigm eventually edges out all other possible ways of revealing the world; technology becomes the only story we hear.2–4When applying the enframing stance of the device paradigm to critical care, the search for health becomes separated from human involvement and reduces the implementation of technology, which will make the commodity (health) available to anyone who has access to the device. Physicians, nurses, and other healthcare providers in critical care units are at risk of being absorbed into this paradigm that reduces life and health to commodities and also reduces medical and nursing interventions to technological devices. From the perspective of most patients and families, the device (eg, mechanical ventilator, intra-aortic balloon pump, ventricular assist device, or hemodialysis machine) that promises to produce the desired outcome is not visible to them, much like the mechanism by which heat is produced in my house is not visible to me. For patients and their families, critical care can be perceived as a sort of “black box” where patients are expected to enter, be subjected to whatever device is needed, and emerge alive and healthy to rejoin their communities. In contrast to the patient’s and family’s experience, the critical care practitioner experiences the same environment as one in which understanding the technology and how it works to achieve the desired end is of great importance. For example, when a critical care nurse participates in implementing intra-aortic balloon pump technology with a patient in cardiogenic shock, the nurse’s understanding of the workings of the machine is essential to its effectiveness and safety. For example, when a critical care nurse participates in implementing intra-aortic balloon pump technology with a patient in cardiogenic shock, the nurse’s understanding of the workings of the machine is essential to its effectiveness and safety.Despite these different perspectives, patients, families, and critical care practitioners often perceive the technology as the means by which a desired outcome—life and ultimately health—is produced. When we approach critical care from the perspective of the device paradigm, we bring technology to the foreground and focus exclusively on the technological device, thereby reducing nursing and medicine to predictable interventions that can be employed as devices and leaving little or no space for the complexities of human involvement and judgment required in these practices. This means-end or instrumentalist view of technology in critical care encourages participants to take a detached stance; to attend to manipulating the technology; and to resist the distraction of, for example, emotional involvement.For some nurses and physicians in critical care, technology provides justification for the exclusion of families in the interest of maximizing the efficient and safe implementation of needed devices. Similarly, the device paradigm taken up by families encourages them to stay uninvolved in care since they have no expertise in manipulating the technology and it is the technological device that makes the desired end available.The promise of technology is that it will predictably and consistently produce a commodity with as little intrusion into human life and experience as possible. The potential efficiency of the means-end device model is compelling given the expanding demand for life-saving technology, limited resources, and the tendency of the US culture to focus on commodification. Commodification turns life and health into predictable and reproducible goods available to individuals rather than recognizing them as dynamic processes of involvement with all life and the environment that sustains it. The more we individualize and commodify health, the more we distance ourselves from the interconnected web upon which the health of all life on Earth depends.In further discussion of Heidegger’s2 ideas on technology, Malpas5 describes how technology gives a simplistic account of human involvement in the world. Technological enframing covers the world in all of its complexity and leaves us with representations rather than with any closeness to or understanding of the richness and depth of the world. Technology at its worst reduces our access to the world and to life to representations accessible only through devices. Ultimately, this limited view of life as representation results in conflict.As healthcare providers in critical care, we disagree with each other and with patients and families regarding what ends we can expect technology to make possible and what should be considered desirable outcomes. In discussions about when to limit treatment, a physician may hold the view that a cure is possible based in part on representations of life, such as vital signs and laboratory values, whereas the nurses involved in the care of the same patient may think it best to shift the focus to comfort care. In another conflict between providers and family members, the family may believe continued life is most important, whereas nurses and physicians feel strongly that permanent loss of consciousness and cognitive function represented in responses to formal clinical testing and imaging is clearly a circumstance in which treatment should be withdrawn.There are many representations of life in the critical care unit: for example, vital signs, laboratory values, and the proper functioning of the machines that sustain these signs of life. But does knowing the spontaneous tidal volume bring us any closer to understanding the life it represents? According to Malpas5 and also Borgmann,4 knowing specific details like tidal volume can take us farther away from what the technology represents and leave us with the representation alone. What brings back the closeness of life is knowing the person to whom the tidal volume is connected. When we let it, the intimate space of our practice as nurses and physicians takes us into the process of emotional engagement with the patient and family in which we hope to understand their experience and begin to know the ways in which they are involved in life, health, and illness.In contrast to technologic enframing and the device paradigm, practice that opens a space of disclosedness reveals all of the ambiguity and underdeterminedness that make up the world of human involvement.1,3,5,6 While this introduces more uncertainty, the space of disclosedness also allows for the possibility of shared understandings and exposes our connection to something bigger than our individual selves.1,3,6 Critical care practice at its best uncovers this space of disclosedness by taking an individual understanding and holding it open as a shared and public understanding that exists between and among people. This is the privileged space that nurses and physicians describe where they bear witness to the human strength and frailty in themselves and in patients and families coping with critical illness, recovery, or dying. Opening up a space of shared understanding involves listening to the narrative experience of the other. Two thinkers who draw attention to disclosive practices that focus on the importance of narrative in medicine are Halpern7 and Kleinman.8Halpern7 advises physicians to cultivate curiosity about their patients’ experiences and points out the importance of listening to the patient’s story. In Halpern’s words, “teaching empathy involves…a change in medical culture from emphasizing premature knowing and certainty toward maintaining curiosity. Physicians who cultivate curiosity about others, sensitivity to their own emotional reactions, and an ongoing capacity to see the patient’s situation, motives, and reactions as distinct from their own are likely to develop increasing empathic skills.”7(p135) Citing the work of Charon,9 Halpern suggests medical students (and I would suggest this as an equally valuable exercise for nursing students) write the story of illness from the patient’s perspective as one way to begin to promote empathy. Developing empathy allows the healthcare provider to engage in a meaningful relationship with the patient and to come closer to knowing the patient’s world rather than projecting one’s own understanding onto the patient’s situation. This empathetic relationship between provider and patient is one in which true autonomy without abandonment can be realized.Along similar lines, Kleinman8 points to the importance of the narrative in describing and helping the healthcare provider understand the patient’s illness experience. Though Kleinman’s work focuses on chronic illness, his attention to understanding illness from the patient’s perspective is as important to critical care settings. The “mini-ethnography” Kleinman describes can help the critical care practitioner gain entry to the patient’s and family’s experience and draw attention to the practitioner’s own experience and understanding. The first step in the mini-ethnography is to elicit the patient’s and family’s explanatory model of disease by asking, “What do you think is wrong? What caused it? What do you want me to do?” In seeking answers to these questions, the critical care provider takes a curious and open attitude rather than an attitude of testing or challenging. The critical care provider then describes his or her own explanatory model, most likely a product of biomedical science.Kleinman8 and Halpern7 both stress the value of storytelling or narrative in medical practice. By listening to patients’ and families’ narratives of their illness experiences, critical care providers can move away from technological enframing and into a practice that discloses. As the other’s story enters public space, or what Taylor6 calls the “space of expression,” it becomes a thing shared rather than a private experience contained within one mind.6Relying on and expecting technology to create a desired end tends to give the device more power than it actually has and gives us unjustified confidence in our abilities as manipulators of the device.5 In the end, enframing allows the means to define desirable ends. Instead, we as critical care practitioners should take up technology as only part of a practice that opens a space of disclosedness and lets the patient’s story and experience of illness come to the foreground, giving us access to the patient’s and family’s world, a chance to compare it to our own, and a chance to understand what might be desirable to them.In the current critical care environment, the technology takes a lot of time and attention. Given the power of technology and the clear desire of all those involved to limit the time any patient stays in the critical care unit, it is tempting to streamline services to focus primarily on the devices involved and the representations they provide. This approach is much more efficient than letting the patient and family have a voice. But if we have time only to attend to the technology, perhaps the demand for critical care is in some ways outgrowing the capacity of critical care practitioners to provide that care conscientiously.The author thanks the research team of the Carnegie Foundation for the Advancement of Teaching’s study of nursing education for help in developing and clarifying some of the ideas in this article.