Taking care: Practice and philosophy of communication in a Critical Care follow-up clinic

Intensive and Critical Care Nursing (2013) 29, 158—165

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Taking care: Practice and philosophy of communication in a Critical Care follow-up clinic Anthony Hazzard, Wendy Harris ∗, David Howell University College London Hospital, United Kingdom Accepted 26 January 2013

KEYWORDS Critical Care; Follow-up clinic; Communicative issues; Hermeneutics; Critical theory; Therapeutic consultation; Patient’s agenda; Hallucinations; Delusions; Memory; Relatives; Systems theory; Communicative action

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Summary Human consciousness is inextricable from communication. The conditions of communication in the clinical context are defined by the caring intention and the unequal relationship, which imply special responsibilities on the part of the clinician. The conventional hermeneutic model of communication proposes a close examination of the context of the other, and an objective effort to get close to their consciousness by interpretation of their expressions. The clinician is supposed to lay aside subjective factors but make use of her/his clinical knowledge and skills. At University College Hospital Critical Care follow-up clinic, the communicative task involves history taking; partly by questionnaire and partly by attention to the patient’s agenda — assessing needs, providing information and facilitating access to further help. In recent years the provision of Critical Care has become ever more complex, both in terms of the sophisticated medical and nursing techniques it can offer to patients and in the range of conditions it can undertake to treat. This range and complexity is reflected in the variety of problems and consequences that may be encountered at follow-up. Communicative techniques should take account of the emotional vulnerability of patients emerging from severe illness. Attentive listening should identify special anxieties, and care with phraseology aims to avoid further distress. Issues of memory, depression and trauma may be expected, and the interview technique must be flexible enough to offer emotional containment if need be. The consultation should be therapeutic in its conduct but should not embark upon actual psychotherapy or seek to dismantle the patient’s defences. Contemporary hermeneutic perspectives emphasise the contextual situatedness of the clinician’s consciousness, and propose a model of communication as ‘blending of horizons’ rather than as objective interpretation. Systems theory contributes to an understanding of the influence on communication of social contexts. With his theory of communicative action, from within the perspective of critical theory, Habermas restores the influence of rational critique in the practice of communication, but also as an ethical regulator, especially through the notions of dignity, vulnerability and needfulness. © 2013 Elsevier Ltd. All rights reserved.

Corresponding author. Tel.: +1 207 1555000x73367. E-mail address: [email protected] (W. Harris).

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Communication in a Critical Care follow-up clinic

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Implications for Clinical Practice • • • •

Summary of thirteen years’ clinical experience of Critical Care follow-up. Emphasis on communication with Critical Care follow-up patients. Possibly helpful towards planning of new follow-up clinics. Possibly useful comparison with established follow-up clinics.

Introduction During the course of the 1990s, the complexity and effectiveness of Critical Care interventions made significant advances, and the Critical Care Unit at the Middlesex and University College Hospitals (UCH) expanded to over 22 beds. At the end of the decade it was decided that patients discharged from hospital after critical care should have the opportunity to attend an outpatients follow-up clinic where their progress could be reviewed. Other hospitals, notably Liverpool Royal Infirmary, Homerton Hospital and Reading Hospital, had already taken the initiative in setting up such clinics for their critical care patients. Early in 1999 the Middlesex and UCH follow-up Clinic was commenced at the old Middlesex Hospital Outpatients building in Cleveland Street. With the closure of the Middlesex Hospital in 2005, the location of the Clinic was moved to the Outpatients area of the new University College Hospital. From the beginning, an appointment has been offered to any patient who has been in Critical Care for three days or longer. The need for such clinics is increasingly wellestablished (Desai et al., 2011) and is recommended in the 2009 National Institute for Health and Clinical Excellence (NICE) guidelines Rehabilitation after Critical Care (National Institute for Health and Clinical Excellence, 2009) and the Department of Health document Comprehensive Critical Care (Department of Health, 2000). Among the research references we have presented as directly relevant to this discussion, four are of foreign origin: three from Scandinavia and one from Greece. It is worth recording, however, that our background literature search revealed critical care follow-up studies from France, Brazil, the Netherlands, Norway, Greece, Sweden, the USA and Hong Kong. This evidence of international interest in the topic indicates a wide recognition of the importance of the principle that the consequences of critical care should be studied, assessed and well managed. The UCH follow-up outpatients clinic is led by a critical care nurse specialist with the support of a medically qualified psychologist and the attendance of a physician intensivist.

Communication in the clinical context It has been maintained by philosophers, psychologists and social scientists that communication is a primary condition of human consciousness. If this is the case, then, as we find ourselves ‘always already’ in a state of communication, the elements of such an existential experience are likely to prove resistant to analysis. A good deal of what we ‘do’ in mutual communication is liable to take place ‘behind our backs’ as, indeed, communication is probably not so much

a matter of doing as of being: not so much what we do, as what we are (Gadamer, 1976). In the clinical situation, the communicative relationship is a special one, confined in focus towards certain purposes that are in the service of caring for a patient and of acting positively towards the improvement of their health. The relationship is also unequal. One party to the relationship occupies the privileged position of ‘knowing better’ than the other about the objective functioning of their body; and even for certain purposes of their mind, whereas the other, the patient, is constrained into a relationship of dependency due to the fact of their illness and, in the great majority of cases, their less informed understanding of the pathological processes underlying and maintaining it, and of the implications of treatment. The University College Hospital follow-up clinic was established in response to a perceived, pragmatic need and has developed its communicative practice in response to whatever needs patients have brought, and continues to develop in the same way. The theoretical perspectives elaborated here are evoked as referential frameworks for reflection upon our clinical experience and modes of communication. With regard to such fleeting episodes of clinical encounter, it does not seem appropriate to appeal for justification to the conventional philosophies of empirical science, so we have presented philosophies of interpretation that are traditionally of use in reflecting upon human interaction. In the context of the clinic, patients arrive having experienced a wide range of serious illness, and often retain manifestations of persistent ill health, physical and nonphysical. Under these circumstances, guidance from ideas about vulnerability and the challenge of understanding the experience of the other is relevant and welcome. Illness compels a person to adopt the role of patient, which is a role that implies a burden of discomfort, inconvenience, dependency and anxiety. As Merleau-Ponty points out, in the healthy state we tend to live our lives perceptually through a ‘transparent body’ which does not impose itself unduly upon our intentions. In illness, however, the body imposes its complexities, requires attention, sets up barriers and constrains us to seek help (Merleau-Ponty, 1962). Any respectable perspective in the field of moral philosophy imposes upon the clinician a duty to pay attention to such a grave imbalance of equality and to find ways of ameliorating it. Habermas links the idea of human dignity to the inevitable fact of our shared biological and social vulnerability (Habermas, 1990); therefore the current extent of a person’s vulnerability indicates the extent of the clinician’s responsibility to recognise their dignified and moral importance. This raises the question of finding some kind of approach to the patient’s experience and of how far

160 a sharing of experience might be possible. Nowadays it is fashionable to talk about empathy, and of entering into someone else’s suffering, rather than sympathy, which signifies, rather, being with or alongside somebody who is in pain or difficulty.

The hermeneutic model of communication Nineteenth century hermeneutists (philosophers of interpretation and communication) set store by a close study of the historical and cultural context within which a person spoke or expressed themselves in the attempt to identify with their experience and attain the closest possible empathy. This has become the conventional model for communication in the clinical situation. The clinician does her/his best to achieve an understanding of the patient’s social and cultural situation and of their social and personal history, in an attempt to form the closest possible approximation to the patient’s consciousness, and hence to interpret as accurately and effectively as possible the patient’s communicative expressions. On the Critical Care Unit itself, staff encounter particular barriers with regard to the interpretation of patients’ communications, as they are often unable to speak and too weak to write. In the clinic the problems are more to do with sensitivity of topics, brittle emotions, and physical and psychological vulnerability. On this model of empathic interpretation towards understanding someone, the process is supposed to be as objective as possible, and indeed the hermeneutic philosopher Dilthey regarded all human utterances and expressions as ‘objectifications of mind’, that is to say, as textual objects capable of interpretation towards achieving access to the conscious experience of the other (Dilthey, 1967). According to this model of objectivity, the clinician is supposed to lay aside subjective influences in the way of preconceptions, prejudices and sources of misunderstanding emanating from her/his own cultural, historical, social or generational situation. On the other hand she/he is expected to bring her/his clinical understanding; the consequence of her/his study of clinical science and her/his clinical experience; into the process of communication for the benefit of the patient, for it is the clinician’s understanding of these matters and her/his taking responsibility for the welfare of the patient that forms the ostensible purpose of the communication.

A. Hazzard et al. stress and depression are commonly found. The prevalence of these conditions has been confirmed by the literature reviews (Davydow et al., 2008, 2010; Griffiths et al., 2007; Rattray and Hull, 2008). A summary of post-traumatic stress after critical care has been presented by Jones (2010). At UCH, a set of questions related to the kinds of problems that experience and evidence suggest are likely to affect patients are presented in the form of a questionnaire (see Appendix), which is usually completed in advance of the consultation. It is a drawback of our questionnaire that, when it was composed in 1999, it owed little to study of the literature, although we took note of what was done elsewhere. Clinical experience has led to some additions, but we have not perceived the need for major changes. It can certainly be objected that a questionnaire forms the very antithesis of free communication, because it can impose the clinician’s preconceived agenda of history-taking and tends to marginalise the patient’s special experience. It is lent justification, however, by the importance of ensuring attention to certain foreseeable problems that can be associated with the intensive care aftermath, such as: breathing, swallowing, vocalisation, mobility and digestive problems, post-traumatic stress, depressive illness and existential adjustment difficulties. It is hoped that the disadvantages of the questionnaire are mitigated by allowing the patient to lead discussion of any topic that arises from it. Another problem with the questionnaire is that adequate discussion of matters arising from it takes time, and may intrude upon the patient’s opportunity for free communication from within their own agenda. For this reason, and in our experience, the critical care follow-up consultation needs to be of adequate length; about an hour or sometimes even longer. There needs to be time for discussion of the questionnaire, for the attention to material initiated by the patient, for an adequate response to problems and concerns, sometimes requiring referral back to the general practitioner or to other specialists, and overall for conducting the consultation in such a way that it serves a generally therapeutic function. In summary, the communicative task involves some sharing of the patient’s subjective experience, identifying the patient’s present and future needs, and the provision of appropriate information, assistance with access to further help and attention to the patient’s agenda.

History-taking: questionnaire versus patient’s agenda

Communication as technique and interaction: inquiry, explanation and containment

The clinical history has developed a special structure devoted to the essential but narrow purposes of diagnosis and the identification of problems. It forms the core of most clinical interviews, but in the case of critical care follow-up the principal diagnostic procedures lie in the past, and major interventions have already been carried out. Nevertheless, some structured inquiries are essential. Firstly the patient’s physical health must be assessed, both with reference to the condition which brought them to intensive care and to subsequent physical symptoms or disabilities related to their admission, or that may have developed since. With regard to non-physical, that is, psychological symptoms, in our experience post-traumatic

A consultation that is designed to include a therapeutic function will help the patient to make sense of their experience and their response to it. The clinician will aim to support the patient’s emotional containment of their situation, and in the context of critical care follow-up, pains are taken to avoid any move that would destabilise or upset the patient’s psychological capacity to function. This may mean backing off from certain questions or topics. The presence of a psychologist in the team makes it possible for a range of potentially therapeutic ways of thinking to be available; for example, the person-centred, psychodynamic, systemic, cognitive and existential theoretical perspectives may be summoned according to what

Communication in a Critical Care follow-up clinic the patient’s material suggests. On the other hand, a single consultation gives little space for the conventionally therapeutic use of any model. From our point of view it is prolonged experience by the same team in the same context that has shaped our communicational practice. Often it is helpful for a patient to be given an indication as to where their experience lies in relation to certain recognised norms. For example, many patients in critical care suffer alterations of conscious awareness related to disturbances of brain chemistry. They may experience disorders of perception or hallucinations, and/or disorders of interpretation or delusions, under the burden of which they may become uncooperative or act violently. Memories or news of these events often distress people afterwards. They may feel ashamed of their behaviour or be anxious about their mental health. The questionnaire inquires into these possibilities and is likely to prompt the patient to give an account of their experiences and subsequent anxieties. When the subject of hallucinations or delusions is discussed, the patient will need space to describe their experiences and their reactions to them, thereby presenting both a verbal and non-verbal text for the clinician to consider. The patient’s verbal and non-verbal text will usually contain some narrative elements, some self-interpretation, expressions of guilt and anxiety, and indications of emotion. Important elements of the text will be: choice of words, focus of anxiety, degree of calmness or agitation and sense of the patient’s degree of trust and stability within the context of the consultation.

Memory Clearly, memory is a significant factor in communication. Many patients are amnesic about at least some of their stay in critical care (Granja et al., 2008) and the resulting gap in their life narrative disturbs some of them. For such patients, the ability to refer to their clinical records and the testimony of relatives and staff can be helpful. Some patients, however, are happier, as least at the time of consultation, not to know, and would rather not be told about what happened to them. Patients who have been traumatised by their illness typically experience recurrent intrusive memories that are accompanied by distressing emotion. Ringdal et al. (2009, 2010) present evidence for the nature and impact of memories after critical care, and the conclusions of Keikkas et al. (2010) literature review are in accord with this research and our experience. Storli et al. (2008) take the hermeneutic approach by examining the potential meaning of reported memories. Memories like this and other forms of emotional distress can inadvertently be ‘cued’ or precipitated by questions or references made during the consultation, which is another reason for being circumspect. It should be mentioned that psychological trauma is by no means exclusive to events in the Critical Care Unit itself. It very often results from events in Primary Care, the Emergency Department, or from anxieties and problems associated with transfer or discharge. Memory impairment, usually of mild degree, is commonly encountered in the clinic. Mostly it seems to be attributable

161 to the psychological shock of serious illness, and with subsequent follow-up is found to improve, but inevitably in the critical care context there will at times have been some risk of actual insult to the central nervous system (Conway, 2005). It is not our routine practice to use a formal test instrument for detecting neuropsychological impairment, but we are on the watch for any indications that would suggest the advisability of specialist referral. For example, persistent loss of capacity in working memory, persistent failure of encoding or retrieval in episodic memory or inability to follow a logical sequence of reasoning, any of these resulting in a significant impact on everyday life, would indicate the need for formal assessment of cognition. If a patient from any cause has significant cognitive impairment, the consultation has to focus more tightly on communication of the most important issues using the clearest possible expressions. The presence of a sympathetic relative can be invaluable in facilitating the conversation.

Relatives With regard to relatives, it is important to bear in mind that a loving relative is likely to have been through an experience as traumatising as that of the patient (Linnarson et al., 2010), frequently more so, because the unremitting stress, caught between hope and mourning, experienced by relatives, is something for which it seems the human psychology is not well prepared. From our experience in the clinic, and in the light of research studies (Davidson et al., 2012; Jones et al., 2004), post-traumatic stress and related problems in relatives are commonly encountered. When a relative accompanies a patient to the clinic, it is sometimes possible to allow them space to explore their own experiences, and to listen to them with the same kind of therapeutic attention that we would offer a patient, but we can only do this opportunistically and not on a systematic basis. If they are significantly traumatised and not improving with time, relatives are encouraged to seek referral for further treatment. As Jones and Griffiths (2007) point out in their review of research on the problem, the needs of distressed and traumatised relatives should be given more dedicated attention.

Language and understanding No discussion of communication would be adequate without a consideration of languages other than English, and especially in London, where a huge variety of languages are in use. In the best of circumstances a professional interpreter whose mother tongue is the same as that of the patient, and who is experienced in clinical vocabulary, should be employed. More often it is a relative who undertakes the role of interpreter and usually this is satisfactory, but it does raise important questions about confidentiality, and sometimes about what kinds of relationship are involved. The whole question of cross-cultural communication is immensely complex in practice, but Dilthey’s philosophical model serves as a guide. In terms of Dilthey’s theory of understanding, with its requirement for the study of cultural and historical context, and also Searle’s notion of the ‘speech act’ (Searle,

162 1969), and Habermas’s theory of communicative action (Habermas, 1984), the ‘text’ of a patient’s expressions constitutes a piece of objective evidence (objectification of mind) which offers to the perceptive clinician some access to the patient’s conscious experience.

Therapeutic effort The clinician is supposed to consider the range of the patient’s expressions in order to formulate an understanding of the patient’s experience and to reflect on their significance. The clinician calls to mind norms and classifications of experiences and symptoms that might be relevant to the patient but at the same time allows for the unique character of the individual patient’s experience. At an appropriate moment, the clinician may offer information to the patient about where their experiences seem to fit among predictable norms in terms of the effects of drugs, hypoxia or other insults upon the central nervous system, of expected patterns of recovery or of persisting psychopathology, related perhaps to toxic hallucinations or delusions. Listening to the patient’s text, accompanying them in their distress and helping them to make sense of their experience, the clinician should endeavour to offer the patient a therapeutic encounter and not an intrusive or destabilising one. The effort to be therapeutic entails careful choice of phraseology and use of silence, whether in response to patients’ expressions or in imparting information. In judging the appropriateness of interventions it is helpful to bear in mind the possible presence of traumatic or depressive pathology related to the patient’s illness, unconscious pressures, and pressures from the social system within which the patient operates. With reference to Searle’s idea of the ‘speech act,’ the active power of any utterance by the clinician should be carefully considered as the patient is so vulnerable and the relationship so unequal. Our experience indicates that earlier, incompletely processed trauma may well resurface, and previous tendencies to depressive illness may be reawakened. Clearly, if a patient is troubled by continuing uncertainty about the outcome and prognosis of an illness they are unlikely to be settled into a tranquil frame of mind. Sometimes the intensity of communication is sharpened when a patient with a previous history of abuse has found that emotions associated with the abuse have been re-awakened by the experience of serious illness and particularly by their experience of critical care. This does not imply, of course, that the care in question was experienced as abusive, but simply that the event was traumatic. Under these circumstances the outpatient interview has to direct itself towards therapeutic containment of the emotional pain, and in doing so to it will require to alter its emphasis, smoothly, swiftly and carefully, responding to the guidance of the patient’s emotional needs. This resurfacing of previous emotionally charged events seems to have something in common with Freud’s ‘return of the repressed’, though not its precise parallel (Freud, 2001). Clearly a single consultation can make no adequate impression upon the deep emotional injuries of such patients, except to add to them if handled badly, so time must be taken to listen attentively, respectfully, without

A. Hazzard et al. pressure or intrusive questioning, and without comment, unless very carefully judged. It is to be hoped that patients experience a degree of relief and comfort from their encounter with us, but it is not we who will undertake their healing psychotherapy, and we must not usurp that potential therapy by ill-considered interventions in an unsuitable context. There may be a temptation to engage too closely with a patient’s deeper problems, so that their emotional defences become destabilised in a context where there are insufficient time, resources or back-up to contain distress or restore equilibrium. There may be too insistent questioning around painful topics, hasty interpretation of a patient’s utterances or a tendency to play down negative experiences, for example, in pointing out that someone is ‘lucky to be alive’. It should be left to the patient to express this kind of compensatory sentiment, if that is what they feel. The particular unpredictability and intensity of the follow-up clinic means that general descriptions can be misleading, but there are certain themes: people come who are grieving for the loss of their previous healthy status, for loss or impairment of physical functions or for the loss of their former self-perception. A surprising number have been bereaved of a loved person in the recent past. Some patients are still affected by a life-threatening or chronic illness; maybe awaiting test results or the decision of a specialist. There are those, as already mentioned, who are suffering from post-traumatic stress, depressive illness, the re-surfacing of previous trauma or other psychological difficulties. There are sometimes family tensions, or practical difficulties with social support, housing or disability: a truly general clinic. Medical and nursing advice can be offered or arranged and practical suggestions made, but often there are no obvious solutions. However, bereavement, anxiety and distress can be met with careful human and professional attention and, importantly, without time pressure. Responses can be made to assure the patient that they are being heard, and that efforts are being made to understand and engage with their feelings and expressions. Appropriate interim counselling can be given from among the psychological perspectives available, with careful attention to the patient’s needs, circumstances and vulnerability, and with an eye to the limits of a single consultation. The aim is that each patient should experience full attention to their agenda, some help towards recovery from critical care, and perhaps even a little comfort, as mentioned above.

Identity and situatedness of the clinician: blending of horizons and systematic reflection Up to this point the model used for discussing communication has been that of the objective, reflective clinician, free of personal preoccupations, striving to achieve understanding of the patient through considerations of context, culture and history; that is, the context, culture and history of the patient. Twentieth century philosophy of understanding, however, sets in doubt assumptions about the self, individual identity and bounded self-consciousness. In other words, doubt is thrown upon distinctions between subject and object, because subjective consciousness is always already

Communication in a Critical Care follow-up clinic ‘in the world’ (Heidegger, 1962) and effected, or shaped, by the environment that supports it. The notion of historically effected consciousness (Gadamer, 1975) proposes that we can never entirely discover through reflection what prejudices, preconceptions and traditions shape our consciousness. The effective history that shapes us reaches out to the ‘horizon’ of our self-understanding, beyond which we become aware of the horizons of others by means of their expressions. Communication and understanding on this view takes place by means of a ‘blending of horizons’ which permits a partial sharing of traditions and concepts, but we need to bear in mind the historically shaped and provisional state of our own consciousness, otherwise prejudice may take place ‘behind our back’ (vide supra). There is clearly little room for the achievement of empathy, or of entering into the actual conscious experience of another person, on this view. The practical lesson of this is that the clinician is supposed to think carefully about the historical, traditional and ideological forces that might have shaped her/his own consciousness, while engaging understandingly with the ‘text’ of the other person, especially if the professional context dictates that communication is an important aspect of the work; and this is certainly the case in critical care follow-up. Such reflection in the context of the clinic should facilitate not only engagement across cultural boundaries, but also across the gap of understanding between patient and clinician. The practical application of a hermeneutic approach in the clinic suggests consideration of the patient’s response to their illness, their cultural and social background and life experience, previous traumatic events, unconscious conflicts and any existential meanings they may have derived. As noted above, direct inquiry about these topics is not always advisable, so time sometimes has to be taken to allow relevant communications to emerge. The clinician, in responding to the ‘horizon’ of the patient, recognises that they are viewing through the lens of their own consciousness, which is shaped among other factors by preconceptions, by cultural and personal history, professional training and experience, and certain normative expectations of actions and events: namely, the ‘horizon’ of the clinician, for which, by means of reflection, some allowance can be in order to avoid too much clinician-bound misunderstanding of the patient’s world, and to make better sense of their expressions. It would be through the ‘blending of horizons’ that the aim of engagement with the patient’s experience and agenda might be achievable.

Group and family systems Even less deference to the conventional, individualist model of the mind is shown by systems theory. From the systemic perspective, each mind lies at a certain point within a permanently active communicational network. Rather than the mind organising communication, the mind itself is continually organised by the structure of the network of communication within which it finds itself. Reflecting upon this perspective helps the clinician to take into account the group communicational influences that might be acting not only upon the patient and their relatives, but also upon

163 themselves (Davidson et al., 2012). The potential power of systemic structures to shape consciousness is also significant for the way care delivery services are organised. For this reason it is important that the management of clinical services and of their context should be as sympathetic as possible.

Critical theory and communicative action: Habermas and dignity: Levinas and the needful other Despite the post-modern drift away from bounded selfconsciousness as a model of the mind, the philosopher Jurgen Habermas invests heavily in the value of rationality. His theory of communicative action recognises the various kinds of influence that history, tradition, culture and prejudice bring into the exercise of communication, but nevertheless maintains that respectful communication and agreement can take place. In his view the benefits of communication emerge from the potential capacity of each participant to leave aside individual presuppositions and engage in a rational discourse, free of threats and compensating for the pressures of ideology: a rational discourse that, as it were, ‘floats above’ prejudice. Of course, this ideal speech situation (Habermas, 1970, 1975) is more a ‘regulative idea’ than an achievable state, but it is something to strive for, and to help inform the clinical encounter. The lesson of this perspective to be applied in the clinic is to regard the consciousness of both patient and clinician as a product of both ideology and unconscious influences, and for the clinician at any rate to recognise this. According to critical theory, it should be possible to put on one side this unavoidable background, with its potential for misunderstanding and irrational opposition, and for the shared capacity for reason to open a space within which mutual understanding and common purpose can be negotiated. Patients, when they arrive at the clinic, have inevitably internalised deep and intense impressions of their perilous time as profoundly dependent inhabitants of the critical care department, with its alien ambience and technical dominance. It is very easy for them to have interpreted events there in very different ways to nursing and medical professionals, especially if they suffered hallucinations or delusions. At the same time, clinicians, with their much greater technical understanding and familiarity with the customs and environment of critical care, carry a set of assumptions that may impair their openness to the patient’s views. This is one situation in the clinic which can illustrate the useful guidance of critical theory. Overall, the view of Habermas, despite all sources of ‘false consciousness’, internal or external, and despite postmodern and post-Holocaust scepticism about the efficacy of reason, is that enlightened reason and reflection, aided by the corrective reasoning of others, is the ultimate guarantor of good communication and safe outcomes. He believes it is possible to rehabilitate the Enlightenment. The principle of human dignity is liable to become marginalised by a radical market ideology which rather promotes the ideas of ‘user’ autonomy, competition and empowerment. Certainly a person’s autonomy should be respected, but on the other hand patients are anxious that

164 ‘care services’ should genuinely care for their dignity when they are vulnerable and dependent (Campbell, 1994). For Habermas, human dignity is a factor of our vulnerability vis-à-vis each other, and has nothing to do with power (Habermas, 1990). Therefore the vulnerable patient, often in the throes of anxiety, is especially dignified and has a particular claim upon our carefulness. For Levinas it is the human encounter in the face of the needful other that bestows responsibility upon us and that gives communication its foundational importance (Levinas, 1998). Our patients have been our teachers and we owe to them the respect of thinking carefully about communication and working hard to optimise our practice.

Conclusion During and after a period of critical care a person is bound to experience an attenuation of their customary capacities, leading to a state of enhanced vulnerability and dependency whose attributes, philosophers indicate, are at the heart of human dignity and value. For the clinician, the encounter with such attributes imposes a formidable testing of the virtues of practice (May, 1994), among which the exercise of sensitive and informed communication surely belongs. Human communication is a huge subject drawing on physiology, sociology, linguistics, history and cultural studies among others. Correspondingly, care of the critically ill and its follow-up entails a huge range of communicative challenges. Habermas places the disciplines of communication and understanding alongside both those serving the technical interests of positive science; devoted in this context towards healing; and those serving the emancipatory ideal of critical theory (Habermas, 1987). Ideally, clinical practice takes account of all of these. UCH Critical Care follow-up began with a rather amorphous encounter between the clinical disciplines of medicine, nursing and psychology on one hand, and a population of patients emerging from severe illness on the other, each patient’s individual situation posing its own challenge to understanding. This paper attempts to make some sense of our experience over 12 years of these communicational challenges, along with an appeal to some speculative frameworks from the philosophy of social science.

Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/ j.iccn.2013.01.003.

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