Table 3 Values and healthcare personnel roles

Justice

"Yes, I have treated homosexuals, and I relate to them normally."

"You treat everyone the same, you give them [prisoners] the same attention as the rest. I mean, if you have to treat them, and you have to do it that way. I think that maybe it's a risk of the profession, but either way, it's the patient and you have to... treat everyone the same... equally."

Respect

"This has indeed happened. I have a patient with HIV, and ever since he first came to me, he told me, 'You know what? Neither my mother, nor my siblings know I am HIV positive, and I don't want them to find out'. Therefore, I believe you have to respect the patient's decision; if the patient is conscious, if he's oriented, you have to respect his ideology."

"I'd say that in case I don't really need to transfuse him, I wouldn't do it, and not for my personal security or the patient's security, but because one tries to respect the parent's decision, but the first thing to do is to convince them to go ahead with it."

Compassion

"We had lots of friction with them. All the personnel had frictions with that family. Then, I talked to the wife, who felt awful because she could not get any money because she had already sold everything. I told her to draw close to any religious faith. It is as if you were changing somebody's life; a psychologist must intervene; something must be done to make them sensitive, to help them improve. It was not until I told the woman to start working that she told me she did not know how to do anything. However, I told her she needed to help her husband, and the man was not making any progress. It took her, like three months; the woman started working, and it was very hard for her."

"I put myself in the patient's shoes. I have always said to my daughters and husband, if I come to this [need of resuscitation], I am against doing everything until the end; tubing him, giving him electric shocks in the heart. Tubing him all over is just tormenting the patient and his family, too. It is very hard to come and see your loved one with tubes all over; it's shocking. I have always said that I don't want that for me. I wouldn't do it either to someone else."

Benevolence

"I chose nursing. To tell the truth, ever since I was a kid, I liked the whole helping situation, being always aware that my brother was sick, and me being there, helping him. It's as if I always thought of having to be there, giving something to others."

"One just doesn't [treat him]. And yes, we have been asked, and one just doesn't do anything. One waits for the end. You just stay there with him, but let me say we never leave them alone. They go into cardiac arrest and all, but they do tell you, "If something happens to me, I don't want to be tubed or anything like that", but you just stay there, with him. I mean, I don't know, you talk to them, maybe even pray or I don't know, but you just stay there."

Professional Humility

"Youngsters are forgetting that here in Mexico we practice a clinical medicine, using clinical skills. You must figure out many things. Just by simply exploring the patient, I can get a feeling that the problem might be this or that, and I support my opinions with lab tests in order to confirm or rule out anything. Now, it's going the other way. If a patient tells them they have a headache, they send them for a CAT scan and forget about the rest. That is why, nowadays, we are having so many problems. Because it's true; you can always send them for a CAT scan, but you neglect other skills."

"Now, I have to accept that perhaps they want to take other opinions, visit other surgeons, or maybe they don't want to be operated on. Maybe there's another alternative, and one has to accept that."

Self-direction

"When a patient does not follow the treatment, I comply with the rules by telling them what they need to do. I tell them what their problem is because I cannot go to their place and take care of them. They are old enough, and they are responsible. I try to make the patients feel committed so that they don't blame the doctor."

"I go to my colleagues at the ER, and I help them to set up an IV for a patient in pain. I just stay with my pregnant patients, or I go with my vaccination colleague and help her capture the data about the shots the patients are getting."

Compliance with standards

"That has also happened to me with certain religion that prohibits this. In this case, the family and the patient were told about the risks if he was not transfused, and in spite of everything, of the complications and all, they refused. One has to protect oneself, and you can ask them to sign their refusal of treatment, despite being informed, and that way one is a bit more protected. One tells them about the consequences; if they do not accept the procedure, it is their responsibility, one simply informs them."

"In this case, we would need to talk about it [a do-not-resuscitate order] with the family and the patient, in writing and in accordance, if the patient is conscious and aware of what he says, in control of himself. We need him to be capable. Many people express their will during their lifetime, they make it evident for their families, it is the same for those who want to donate organs: 'You know what folks, if something happens to me, I want to donate my organs'. This is very frequent, and in this type of patient, if he expresses his will and is completely conscious, a document is written, and he signs it."

Capacity to appraise situations and consequences

"That has also happened to me with certain religion that prohibits this. In this case, the family and the patient were told about the risks if he was not transfused, and in spite of everything, of the complications and all, they refused. One has to protect oneself, and you can ask them to sign their refusal of treatment, despite being informed, and that way one is a bit more protected. One tells them about the consequences; if they do not accept the procedure, it is their responsibility, one simply informs them."

"One thing that I perceive and admire from the haematologist, for instance, is that, with the patients with leukaemia, she tells them: 'This is the situation: your treatment is not working'. Then, they just remain there, thinking. But she gives them a choice. 'You have to decide; if the treatment is not working, they are going to ask you, if you are going to stay and continue with the treatment. In the meantime, you might pass away, you need to decide if you want to go home and enjoy your family'."

Tradition

"Family intervention is very important because it is the family who brings the patient; even if most of the times the patient comes by himself, the family is the most worried. The role of the family is very important because relatives are the ones who will follow the treatment at home. We only stabilise the patient."

"For me, the family is essential in the treatment. [Family] is the centrepiece of society; very often the failure or success of the treatment depends on the family."

Advisor

"That's why I always try to play music in my practice, all kinds of music, but mainly instrumental music. It's just like they say, music calms the beasts because the beast can be unleashed at any moment. I try to calm down and think about what I am going to say. Tell him why things are going wrong: 'Things might get complicated with this and that'. For me, it has been useful to tell them they are not orders but suggestions or recommendations that I hope they follow. And if they don't want to follow them, I cannot take care of them. They are the ones who will end up worse. It won't be me or their families, but themselves. That works for me; that, I learned with time and with teachers."

"I already enjoyed talking and listening, but now I have better reasons to do so! I do like talking to patients if they tell me about their family and personal stuff, as well as other things. One has very frequent patients; they come here all the time, and you already know them. You know their whole life and work; even their family knows you and identifies you. And well, yes, my attitude has changed. I am more communicative, more participative with my patients too.... For me, the most important thing this course has given me is that: more humility, more... one very important difference."

Educator

"I try to explain their disease to them and how we will proceed in the treatment because I wouldn't like it if someone left me with doubts. Sometimes, I see the doubt in their faces and I try to explain it to them; the same goes with the treatment. I believe we have different educational levels, and sometimes one talks to them with lots of technicalities. Before studying, we also didn't understand a thing, as if we spoke in another language."

"I would make him see that it's necessary, that it's part of the treatment, that there are maybe risks associated to this surgical procedure because he can lose so much blood or have some other problems, and that therefore, it is necessary."

Medical Attention

"I treat everyone. Because I am a family doctor, I treat the child, the father, the mother, the insured, everything. On average, I treat approximately 24 patients a day. I spend approximately 15 minutes with each of them, but sometimes I can spend 5 minutes with one person and an hour with another. Sometimes there is not enough time. You sometimes need more time, but that is compensated for if another patient comes with something simpler."

"They come and tell me: 'You know what? I went with that doctor, and he did not explain anything. I want to know what my problem is. I want to know what I have'. Then, I do research, I go through the medical records and files, I try to reach a conclusion, and well, I try to let the patient know about it."