Emeritus Affiliations: Victoria Hospice, Centre on Aging, University of Victoria
Dancing on the Edge: The Value of Maintaining Therapeutic Boundaries in Palliative Care

Observing boundaries need not remove warmth. Boundaries do not
mean ‘detached neutrality,’ boundaries need to be about passionate,
but trustworthy engagement. Enmeshment/friendship at one end of the
spectrum or 'power-over' professional hierarchy [at the other end] do
not define the full range of appropriate relationships.
- Miriam Greenspan

While the image of the family dance is not new, it reminds us of the importance of paying attention to boundaries as we work with people who are vulnerable and dependent upon us for care. In fact it is often the degree of attention paid to maintaining healthy boundaries that distinguishes a ’helping’ relationship from a ‘harmful’ one and having a conscious awareness of 'where we stand' in relationship to patients and families is a crucial issue in providing ethical care. The image of a family dance floor with a definable edge allows us to envision and explore this kind of awareness, enabling us to work with clarity and integrity without cutting off our feeling selves. When we pay attention to and respect the value of boundaries, we can experience the satisfaction that comes with achieving a heart/mind balance, which in turn allows us to feel deeply, while still thinking clearly and acting wisely.

 

Therapeutic distance and the risks of caring too much

When we work from a ' therapeutic distance', we understand that even though individual and family dances may be similar to ours, they are at the same time, separate and unique. From this place, although we may become intimately involved with patients, clients, or family members as they dance their last dance together and may at times even 'feel like family', we understand that this is different from 'being family'. When we care too much, we lose this valuable perspective and may find ourselves playing the role of the 'good daughter' or 'good son', the 'soul mate' or 'one true friend', blurring the lines between our needs and expectations and those of the person(s) in our care.

In this process, what we fail to acknowledge is that while the family may gain another 'dancer', they also lose a caregiver who can hold the big picture...a perspective that family members who are out there in the middle of the dance floor themselves cannot hold. They also lose someone who can bring a degree of objectivity to a difficult decision making process, as well as a compassionate witness who  will not complicate their family dance, however lonely or clumsy it may be, with their own steps.  A leading cause of moral distress and disenfranchised grief among health care workers is boundary confusion which may manifest itself in a health care worker accusing colleagues of 'not caring as much as they do, ' or conversely, being shocked and saddened when they are not invited to a 'private' family funeral.

Maintaining a therapeutic distance is about being able to clearly identify and articulate the nature of our relationship with patients and families and how that relationship benefits them. In health care, we as caregivers enter the relationship with the patient or client for the purpose of caring for them and meeting their needs, and therefore, our needs must be secondary. This means that we have an obligation to always act in the patient’s best interest by not creating situations in which our own unmet needs or wishes (what I would do in the same situation, or what a good death would look like for me, for example) become the primary focus of the relationship. This does not mean that we should ignore our needs. In fact it is quite the opposite. It means that we have an obligation to do our work with a conscious awareness of our own needs, taking responsibility to have them met outside of the caregiver-patient relationship.

 

Signs that we are on the dance floor

While it is important to acknowledge that crossing boundaries goes with the territory of where we have chosen to work, meaning that we have all 'been there and done that', there are three signs that can let us know when we are 'on the dance floor,' intentionally or unintentionally, so that we can exit via the  'backward shuffle'!

1) Extremes of emotional responses are often indicators that something about the situation or the people in it is resonating with something important, perhaps even unresolved on our own dance floor. The emphasis here is on an extreme, visceral reaction that may even catch us by surprise, not the appropriate, shared grief that we may at times experience in the course of our work. When we have such a strong reaction, we need to ask, 'what is this about?' and 'who is this about? in the context of my dance?”

2) When we use language or engage in actions that imply ownership of patients, this may be another indicator that a line has been crossed.  An unwillingness to share 'my patients'  with other members of the palliative care team or calling in to check on 'my resident' on days off are often examples of  inappropriate feelings of indispensability and ownership and may also demonstrate a lack of trust in our colleagues' ability to care for someone with whom we have formed a close relationship.

3) Needing to control a patient or family's decisions about care or treatment, putting pressure on them to behave in a certain way, or insisting that they accomplish certain things before death are all examples of an inappropriate use of power and influence that generally reflect a belief or value that may be appropriate on our dance floor, but is not appropriate on theirs.

 

Conclusion

'Bounded intimacy' is a phrase that describes quite beautifully the tension between the intimacy and shared humanity that so often characterize relationships in our work, and the 'edge' that protects the uniqueness that belongs to each of us, even in death. Therapeutic boundaries protect the integrity of the family dance while also protecting us from the stress of over-involvement.

However, this may not be as easy as it sounds!  The edge of most family dance floors is fluid and often hard to find, much less stand on. It also takes energy and a personal dance that is nurturing and supportive in order to effectively maintain the heart/mind balance in the midst of grief work. And finally, we must be willing to engage in ongoing self-reflection and collaboration with our colleagues in order to have the clarity that is required to do this important and deeply personal work with integrity and ethical accountability.



References

Causton, E. (online course).“ Maintaining Therapeutic Boundaries: Avoiding the Stress of Over-involvement with Patients and Families” www.LDMonline.ca

Nasrallah, Sandra, M.D., Maytal, Guy, M.D., and Skarf, Laura,M.D., Patient-Physician Boundaries in Palliative Care Training: A Case Study and Discussion. Journal of Palliative Medicine: 12(12) 2009: 1159-1162

Remen,R. (1996) Kitchen Table Wisdom. New York: Riverhead Books.

Santorelli, S.(1999) Heal Thyself. New York: Belltower Books.

Victoria Hospice Society (2003) Transitions in Dying and Bereavement. Baltimore: Health Professions Press.