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Marc Antoni Broggi: “No idea can disregard the dignity of a person”
Marc Antoni Broggi Trias (Barcelona, 1942) is a surgeon.
On 20 April he visited Mundet Campus to give a talk to students of Social Work from the Faculty of Pedagogy, invited by professor from the Department Social Work and Social Services Cristina Rimbau.
He has been a promoter of bioethics bodies from the Catalan government and has published many works on the doctor-patient relationship, clinical information, patient autonomy and rights, anticipating wishes and ethical committees.
During the month of August, we retrieve some of the interviews that were published on the web page of the UB throughout the academic year.
Marc Antoni Broggi Trias (Barcelona, 1942) is a surgeon. In the private practice he follows his father’s steps, Moisès Broggi, in the public sector, after working for some years at the Vall d’Hebron Hospital, he was head of the Department of Surgery of the University Hospital Germans Trias i Pujol, where he is emeritus doctor. For more than twenty years, he has combined his surgery work with the study of bioethics. He has been a promoter of bioethics bodies from the Catalan government and has published many works on the doctor-patient relationship, clinical information, patient autonomy and rights, anticipating wishes and ethical committees.
Doctor Broggi, who currently presides the Catalan Bioethics Committee, has recently published the book Per una mort apropiada, where he reflects upon the importance of having a realistic and global idea of the decisions that have to be made when death approaches, and the kind of help that can be offered or that we can offer. On 20 April he visited Mundet Campus to give a talk to students of Social Work from the Faculty of Pedagogy, invited by professor from the Department Social Work and Social Services Cristina Rimbau.
In your book you explain that, when death approaches, one must know how to accept what comes and act appropriately. It is not an easy challenge, how can we face it?
We should start by trying to understand the situation and understanding the difficulties of approaching death, both for those who are approaching it and the closest loved ones. Moreover, it is essential to understand the need for company the person who is dying has. Family members cannot delegate medical professionals some things that only they can do, such as company, which must be as attentive and respectful as possible.
What does a proper death mean? Is it the one that tries to avoid pain and not to introduce new suffering?
Yes, precisely. On the one hand, the most important thing we try to avoid is patient’s pain. We try to fight pain and suffering. The feeling of loneliness is a condition that can be avoided with attentive company, holding hands at a given time… There are small details and small aspects that are well within our reach and that can contribute to help the patient to have the feeling that they are in control of the process. Patient’s fear is mainly due to the lack of control.
On the other hand, regarding the goal of not introducing new suffering, we try to avoid useless treatments that may lead to unpleasant situations for the person; we try not to unnecessarily prolong the agony. Waiting time, for example, introduces pain and suffering to the people.
Yes, you explain it very well in the book. Sick people have a different notion of the time…
Yes, they have a completely different notion of the time. If you tell a friend who is ill that you will go and see him in ten minutes but you go there twenty minutes later, the wait will seem to go on forever and he will think that you have forgotten about him and that you won’t go to see him. An ill person feels far away from the world of the healthy people.
Often, death scares people. Nobody is ready to accept that they must die or see a loved person die. How can we become familiar with something that scares us?
You have no choice but to end up accepting the situation, which is going back to nature. If you don’t accept it, you won’t have a pleasant death, unless you die all of a sudden. People who fear death usually ask to die suddenly or sedated and without being told.
In the book you say that in order to get ready to die, an important question is to forgive yourself and get rid of any pending debt.
When the end of life approaches —and this is one of the reasons to properly inform the patient—, we hope to have the possibility to put it in order, to close it, to forgive ourselves for not having made the most of the life that is about to finish, or to patch things up with one daughter, say goodbye to the closest people… There’s a verse by Quevedo which I like very much that goes: “Llegue rogada, pues mi bien previene; hálleme agradecido, no asustado; mi vida acabe, y mi vivir ordene”. When approaching death, we should be able to put our life in order, end the cycle … And we cannot hinder this.
The sick person, then, should know that he is dying…
We believe it’s the best because, in theory, you can make the most of the remaining time before death.
Even if they don’t want to know it?
No, not if the person doesn’t want to know it. Lucidity before death shouldn’t be imposed. It depends on the person and the moment. Some people who were ready to face death at a given time may don’t want to do it later, and we must adapt to it, we must customise help. But customising help doesn’t mean imposing things. If someone wants to die without knowing that he’s dying, we must accept it but we cannot encourage it.
As a result of your experience, would you say that sick people tend to want to know the truth?
It depends. Most people claim that they prefer to know it. However, relatives usually think that ill people are less unable to understand and accept the situation than they really are. We tend to overprotect the people we love.
Hence, a good advice for relatives would be to listen to the sick person, wouldn’t it? Because sick people usually express their need to know the information or not.
Exactly. Before informing the other person, we must know about their need for information. The patient must have the feeling that he knows the information we have and that we’re not going to impose it if he doesn’t want to know about it, but that we’re not going to hide it if he asks for it.
Doctors have historically struggled to fight diseases, in the first place.
Yes, because diseases cause pain. The difference is that we now struggle to help one person, which means fighting the disease, at a given time and, at another time, fighting pain.
How and when do you decide to prioritize the fight against pain instead of the fight against disease?
In those cases when the disease has reached a point that we know the person will die. Otherwise, we must fight against the disease, unless the patient doesn’t want to keep on fighting. There are a number of actions, which I mention in the book, that are fundamental: the first one is precisely the fight against pain, whether there is an illness or not. The second one is respecting patient’s refusal of actions. We must know that the patient can set limits and they must be respected although we regret it. If a patient doesn’t want to be operated, we cannot force him to have an operation. And, the third one, apart from having fight against pain, with sedation if necessary, and from having accepted the patient’s refusal of treatment, besides, we must also be ready to stop when we know that our actions are useless.
How do you determine that they are useless?
The patient may have previously set or not the objective, but if he hasn’t done it, we must set it. The objective cannot only be acting. For example, we cannot keep on having a patient in coma or in a vegetative state only because he is already intubated. This isn’t a valid argument. No idea can disregard the dignity of a person, as it goes first. A consideration that should be taken into account is that, currently, futile treatments are being done only so that the patient can have the feeling that something is being done.
In your book you devote a chapter to distinguish between proper death and euthanasia. What is the main difference?
The main difference is that euthanasia causes a death that wouldn’t take place without it. One thing is causing a death that wouldn’t take place without euthanasia, and another completely different thing is letting it take place when the patient doesn’t want to do anything to postpone it, in the first place, or when we think that postponing it doesn’t make sense.
What is the role of social worker in this process?
Carers are afraid of patients’ questions, of not acting properly, of feeling tired..., and they feel helpless. That’s why it’s so important that social workers can give them instructions and guidance. They have a fundamental role because they can listen to the carer and the family members, who, knowing that they have someone by them, feel much more reassured. The role of the social worker helps the family to reflect upon the reasons behind each decision taken at this time.
During your career as a surgeon, how and when did you start worrying about the fight against pain?
My research in bioethics has helped me a lot. I got involved around twenty-five years ago, in a way because I noticed that, in front of the changes we were facing, I needed some reflection. Otherwise, I couldn’t explain a series of things: I couldn’t explain this change in society, which was moving from being extremely infantilized to wanting to claim autonomy, like the informed consent. This created a brutal change in the environment, in our practice, and I saw that it wasn’t a matter of getting a defensive position, which is the most common one, or longing for the past, but a matter of reflection.
I sought this reflection —and I ended up finding it— in one thing that was then beginning: bioethics. There were other professionals who were in the same position. I found in bioethics a habit of rational and multidisciplinary reflection, which aimed to help make decisions. I didn’t want to find the good decision, but to take the best decision for any specific moment.
From there on, I got used to reflecting upon what we did and how we could improve it. When analysing it, we soon realised that there were many things that had to be changed. The first one was that people shouldn’t suffer things they didn’t want to suffer. And the second one is that people were dying in worse conditions. Not because they were badly treated —because it is precisely the opposite, they are better treated—, but because people have the feeling that they cannot decide by themselves. Before they couldn’t decide either, because nothing could be done… Now, however, many things can be done and we must decide what to do or not depending on what is intended.
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