The SQ

These cases illustrate a concept we have coined, the SQ. The SQ can be thought of as a ratio describing the relationship between perceived individual (or small group) suffering and the overall ambient suffering of the contextual population.

\begin{align*}&{\text{The Suffering Quotient }}\left( {{\text{SQ}}} \right){\text{ = Perceived Individual }}\\ & \quad \left( {{\text{or small group}}} \right){\text{ Suffering/Perceived Population}}\;{\text{Suffering}}\end{align*}

Suffering is complex. Cassell (Reference Cassell1991) described it as “the distress brought about by the actual or perceived impending threat to the integrity or continued existence of the whole person.” Others have described it as having a component defined by relationships with others (Daneault et al. Reference Daneault, Azri and Ummel2022) and as having an objective component that can be perceived by others (Tate and Pearlman Reference Tate and Pearlman2019; Van Hooft Reference Van Hooft1998). It was this perceived distress, which was objectively observed and labeled as suffering by the palliative care staff, that led to the concept of the SQ.

Application of the SQ

In the first 2 cases, the patients were on the same palliative care ward. Hence, the contextual suffering of this population at the end of life, the denominator, was the same. However, in the first case, the suffering of a 9-year-old child left alone outside a hospital while her father was dying inside was perceived to be untenable to staff, i.e., the numerator was inordinately high.

In Case 3, the patient was the only dying patient on a surgical ward. His situation and the magnitude of his suffering were perceived as unique enough to grant an exception to the restrictions. However, when he moved to the palliative care unit, while his individual clinical circumstances remained the same, the degree of suffering within the baseline population he was being compared to – the denominator – expanded. His suffering was not perceived as unique or inordinate relative to other patients on the palliative care unit, and this lowered the SQ.

Suffering cannot be described in terms of absolute values for the numerator, denominator, or SQ. However, the higher the SQ, the more likely health-care providers and others are moved to act. In contrast, for individuals and families, suffering is perceived within the realm of their own experience, and as such, their suffering is substantive, intolerable, and independent of the experience of others. Hence, SQ is only relevant from the perspective of the observer, not the observed.

The SQ, compassion fatigue, and observer variables

Despite acknowledging public health risks and accommodating visitation restrictions with virtual communication, families reported bedside presence was irreplaceable during the pandemic (Mercadante et al. Reference Mercadante, Adile and Ferrera2020). Prohibiting visitation interfered with connectedness and tasks associated with anticipatory grief. This was difficult for our frontline palliative care providers, who define the unit of care as patients and their families (Guo et al. Reference Guo, Zheng and Jacelon2022; World Health Organization 2020). This led to multiple instances of moral distress, injury, and compassion fatigue (Mewborn et al. Reference Mewborn, Fingerhood and Johanson2023; Rushton et al. Reference Rushton, Thomas and Antonsdottir2022) within our staff. The high and increasing rate of burnout we observed in our staff was similar to what has been previously reported in the literature (Baqeas et al. Reference Baqeas, Davis and Copnell2021; Boland et al. Reference Boland, Kabir and Spilg2023; Lluch et al. Reference Lluch, Galiana and Doménech2022; Wang et al. Reference Wang, Grassau and Lawlor2020).

Fernando and Consedine (Reference Fernando and Consedine2014) described a transactional model of compassion fatigue, indicating that a physician behaving compassionately toward a patient reflects the dynamic influences of physician, patient, and clinical and institutional factors. In a pandemic, decision-making is set by various regional and institutional authorities and is very complex and often changing. It requires multiple health-care providers (not just physicians) to make very challenging decisions. These decisions are based on compassion for the patient and family but are also weighed against the consideration of risk for other health-care professionals, their own families, the health-care system, and societal well-being. While the transactional model is very useful, it does not gauge the influence of these various relationships. However, the SQ offers a possible formulaic prediction of observer response, reflecting the threshold beyond which the care provider is moved to advocate for the patient, and ultimately how far they might be prepared to go.

As the SQ is to be interpreted from the perspective of the observer, factors that can potentially influence the numerator become important considerations. It is difficult to ascertain exactly how an observer intuitively measures the perceived suffering of another person. However, implicit bias, seeing themselves in the suffering of others, the culture of clinical advocacy, the risk of institutional discipline or criticism, and other individual characteristics all play a role in the perception of, and the decision to respond to, suffering (Davoodvand et al. Reference Davoodvand, Abbas and Fazlollah2016; Thacker Reference Thacker2008).

In a set of social experiments by Callan et al. (Reference Callan, Dawtry and Olson2012), participants perceived the suffering of older persons as less unfair, and this reduced participant willingness to help older persons in need. Indeed, age-based discrimination has been well described in palliative care, with older patients generally having less access to specialist palliative care services and less adequate symptom management (Dobson Reference Dobson2005; Kotzé and Roos Reference Kotzé and Roos2022; Lloyd et al. Reference Lloyd, Kendall and Carduff2016; Rostoft et al. Reference Rostoft, Thomas and Slaaen2022). The numerator may also have been higher in Case 1, as the young age of the patient and his family may have resonated more intensely with the clinical staff, who could envision themselves as being the young patient or his spouse. This is consistent with the work of Davoodvand et al. (Reference Davoodvand, Abbas and Fazlollah2016), who described empathy, and envisioning themselves in the patient’s shoes, with increased patient advocacy from nursing staff.

Slovic (Reference Slovic2020) described a concept of psychic numbing to explain how people deal with mass atrocities (Resnick Reference Resnick2017). He described psychic numbing as a paradox that occurs because people are unable to process large-scale suffering. In his work, he noticed that, as the number of individuals affected by tragedy increases, our willingness to help reliably decreases (Resnick Reference Resnick2017). This is consistent with the essence of SQ, where observers are less likely to be moved in the setting of a high denominator. The literature also describes the use of individual stories to help the public to really appreciate the suffering of a single person and aid with fundraising (Bhatia et al. Reference Bhatia, Walasek and Slovic2021; Slovic Reference Slovic2020).

Predicting observer response and increasing advocacy

It is not possible to know for certain how health-care workers might act in future situations when faced with patient suffering, and further study is certainly needed. However, the SQ may be thought of as a tool to help predict potential observer responses and improve advocacy. For example, in situations where immense suffering blunts the compassionate response, the SQ suggests there may be 2 conditions in which observers might be compelled to help relieve the suffering for individual patients: by the patient having a uniquely distressing story of suffering, or by the patient receiving care in an area where ambient suffering is less. In daily practice, we should consider both conditions when we advocate for our patients by presenting their stories, and when we determine the best place for their care.