Décisions prises à la place d’autrui : de la complexité des intentions soignantes

Abstract

BackgroundThe research on which this article is based was conducted under a doctoral studies in clinical psychology. The question deployed around psychic intentions and processes in decision-making in the place of others in end-of-life situations allowed for field research to be carried out through observations and interviews with palliative care professionals. Among the three “clinical triangulation” examined in the thesis, we choose to focus on a particular configuration that allows us to highlight the negative affects that sometimes take place in the care relationship and how these affect the decisions we make in place of our patients. ObjectivesIn this presentation, we try to highlight certain unconscious movements that seem inherent to the helping relationship with the vulnerable person, but exacerbated when meeting “deviant” patients (non-compliant, in refusal, etc.). We will see how this negativity, caught in unconscious alliances (R. Kaës, 2009), can generate situations that sometimes involve real care violence (Ciccone et al., 2014). It seems essential to better identify these potential situations in order to guarantee ethics in the decision-making processes that permeate care practices. MethodThe data collection is based on research interviews and observation time carried out in two Palliative Care Units (PCU) located in France, organized in two sessions of 13 days and/or nights. The interviews were conducted in the form of a guided discussion with several professionals (doctors, nurses, care assistants or psychologists) who volunteered to take part. The “clinical triangulations” are the result of a work of recomposition about a patient welcomed in the USP (1st point) from the researcher's observation notes (2nd point) and the professionals’ speeches (3rd point). In this article, M. Aïe's account is presented among the three clinical triangulations supporting the thesis work, in that it offers the possibility of putting into perspective several levels of complexity around negativity and decisions taken in the place of others. ResultsThis presentation provides an opportunity to think about care and decision-making in the place of others in new dynamics. The clinical results obtained from the original research method used in the thesis show the fertility of a work based on the analysis of complex situations through clinical triangulation. This triangulation allows the study of subjective issues that may be expressed at different levels. It is also the group perspective that is highlighted here, in particular through unconscious alliances based on the negative aspects of certain care situations. Mr. Ouch's account allows us to illustrate how hatred is unconsciously diffused within the decisions made for the vulnerable person. These consequences call for us to deploy strategies to try to symbolize these delinked affects. ConclusionDeciding for the other, vulnerable person is no small matter for anyone and reactivates each decision-maker's experiences of being the vulnerable subject for whom decisions were made: the figure of the infant as the original (Ciccone et al., 2012). Faced with extreme situations in life where the ontological precariousness of the subject is at stake, from the beginning to the very end of life, perhaps it is necessary to take up subversive positions (Pacific, 2011) to work on the idea that considering maltreatment as a potential for care can be a prerequisite for good treatment.