One last time.

I told a man he was dying today.  He wasn’t old.  His life had been written for him by his parents and his circumstances, and as we sat there, in his room, in a nursing home, even though he was too young and too cognitively intact for a nursing home, I watched the sun filtering in the window and I wondered why.

How did I come to be sitting here, and him there?  How had I been born to two parents who in spite of their mistakes, didn’t put me in danger, kept me safe, and warm and fed?  How had he been born into the opposite?  What had happened to his parents?

When I told him, he nodded, announced he was tired, then told me I should have worn more makeup to deliver news like that.  It was no surprise to him.  We both had a chuckle.  His writing had been on the wall for a while, and today, more than he was out of time, he was out of fight.  “No hospital” he told me, when I offered a last-ditch attempt to turn things around, “no more”.  I helped him into bed, he intermittently shouted at me, followed by intermittent sheepish silence.  We talked about palliative care, he signed the form with his wishes, not for transfer to hospital, call his social worker when he died, he wanted a funeral in a big church.

I wanted to hear everything.  I wanted to hear all his stories.  Why his bedroom was decorated the way it was.  Who he’d been.  There was no time.  Earlier in the week when I’d met him, he didn’t know me, he shouted at me for the entire visit.  I tried everything I could to try and turn the ship around, but decades of hard living, multiple diseases all conspiring against us, won against my feeble attempts.  When I discussed him with my consultant, she gently suggested it was his time.  There’s always a part of me that wants to fight and she saw this, she let me try.  When I saw him again today it was on his face and in my heart.

I’ve never told a person they were dying before.  On a normal ward job, by the time they get to you, they’re unable to talk or they’re already gone and you’re having that discussion with devastated family.  Today was a long and private discussion, met by my patient with quiet acceptance, with courage, and with peace, in spite of his young age.  There was a both a stillness and a rawness in our words, he was not the sort you could mince words and I’m not the kind to try.

At the time I was focused on making sure he would be comfortable and not be taken into a hospital system that at his stage, would do more harm than good.  We planned a goodbye party.  The chaplain brought him fruit.  Afterwards the nurse and I got in the car and drove to our next appointment.  And it wasn’t for a long time later that the seriousness, the specialness, and the immense privilege of that discussion hit me.

I feel both sad for my patient and happy to know him if only briefly,  immensely humbled to be a part of his final journey, overawed at his bravery and courage in facing it the way he does.  This is why I did medicine.

Something happens to you in medical school.  You forget about why you did it in the first place, you forget you wanted to help people.  You get stunned by bright lights, start trying for the impressive specialties, ditch the touchy-feely stuff in case people don’t think you’re serious about the scientific side of medicine.  You use all the jargon, no lay terms, you pride yourself on it, you assume that those who prioritise caring over the science of it must be covering for their lack of knowledge.  And then if you come to your senses and return to those values, you wake up inside that dream.  When I was done chasing the bright lights and found Geriatric Medicine, I told one of my bosses from a different specialty what I had chosen.  He pursed his lips and shook his head.  ‘What a waste’ he retorted.  I looked him squarely in the eye and loudly disagreed.  I wanted my resident to hear how wrong he was.

When I left my patient today, I said I’d see him again next week.  “If I’m still alive!” he shouted with the sort of cheer that is half joking and half sad.  He is why I did medicine.  I am humbled and rewarded to be his doctor, even for just a few days of his life.

At the end of the day, our team went through our list of patients.  Someone announced he was now discharged from our service, he’d been referred onto our palliative care colleagues.

“He’s not discharged yet” I said out of nowhere.  It’s my first week in this job by the way.   “I can’t.  Not yet.  I need to see him one more time next week, I need to make sure he’s comfortable”.

There is silence.

“So do I” says one of my nursing colleagues.

“Me too” says another.

We keep him on our list so we can see him just once more, and try to help just one last time.

That conversation.

My first rotation in my newly chosen specialty (Geriatric Medicine) is on a ward with a policy of not-for-resuscitation.  I really hate that term.  It’s so loaded, so weighted with the implication that we’d just give up.  The context of this current job is that my patient’s have such severe dementia that they’ve forgotten their families, how to use a fork, tie their shoelaces.  If they were to die from natural causes, say a heart attack, our policy is that we should not attempt to restart their heart, or put them on machines that breathe for them, for the simple fact that it wouldn’t cure their heart problem (there is no cure for old age), certainly not cure their dementia, and cause a lot of pain and suffering for an outcome that at best, would give them a few more, horribly painful days of life.  The alternative is if that something catastrophic were to happen, instead of doing things that would achieve nothing but pain and suffering, we would change our goals to prioritising comfort and dignity.

I am at the start of a conversation that will define my career, and one that as a society we are in the process of defining.  I am loathe to go into the mechanics of what happens in these situations.  They’re traumatic enough for trained personnel.  In the movies and television, there’s about a 70% success rate if you get CPR or shocked with the paddles, or go into ICU on a breathing machine.  In reality, it’s about 20%.  If you’re young.  If you’re over the age of 80, it’s close to, if not 0%.  And yet so conditioned by the media are we, that we hold onto the hope that our loved one will be the magic one, the one that proved the doctors wrong.

So even when I have the discussion with the family members of the patient with advanced dementia, a barely functioning heart, and that near-0% success rate, they still tell me to ‘do everything’, to save their loved one.  But I can’t.  I can’t save them.  You can’t cure ageing (yet) and you can’t cure dying of old age.  Sometimes I’m successful in explaining these principles.  The principles of goals of care, of ‘doing everything’ for anything we can absolutely cure, for not ‘doing nothing’ when we can’t.  We never do nothing.  One of my favourite professors once told me that as doctors sometimes we use medicine and surgery to treat problems, sometimes we use morphine and ice-cream.  The opposite of ‘do everything’ is not ‘do nothing’.  It’s ‘do something else’.

Which brings me to ‘comfort and dignity’.  What does that even mean?  I say it a lot at work, because it’s a goal that resonates.  The mechanics of comfort and dignity is that if Something Bad happens, instead of trying to fix the unfixeable in desperation and poor judgment, we fix the symptoms instead.  If the Something Bad causes pain, we give pain relief.  If it causes distress, we give relaxing medication (similar to Valium), if there are other symptoms, there are things we can do.  The end result of going through that sliding door instead of the other, is a loved one, peaceful in bed, in no pain, and sometimes able to talk to their loved ones in their last hours-to-days.  This is in stark contrast to the CPR/breathing machine situation.  Stark contrast.

I want to be clear that this is not euthanasia.  Euthanasia is a complete can of worms which at this point in time is a dogs-breakfast that I don’t wish to visit.  But symptom-relief and subsequent dignity I’m a big fan.  It doesn’t hasten or bring on death, the underlying disease does that all by itself.  But it does make the path there a lot less traumatic for the patient and their loved ones.

I’m so far down the rabbit hole of medicine these days that sometimes I forget that I’m using jargon.  It’s hard to know if I’m losing my patients families when I have this discussion because 99% of the time they’re so polite.  And yes, it’s my job.  There’s a form I have to fill in with a families plan for their loved ones passing.  I don’t want that to come across when I have that conversation.  I’d love to hear some reader’s experiences of death and what was done well and what wasn’t.  This is a conversation I’m going to have a million times over for the rest of my carer and I want to get it right.

 

Tears in Rain

It’s after hours. I’m doing one of those famed fifteen hour shifts where you don’t sit down. The cardiology fellow is on the phone telling me he’s sending someone up from the cath lab, they’ve just had emergency intervention for their massive heart attack. ‘We couldn’t get access,” he’s telling me, with that calm sense of urgency, “and that femoral sheath can’t stay in – can you have a go when he hits the ward? Otherwise call anaesthetics to do it”.

I tell him I’ll have a go, and wander up. Something about the impossible lights my fire, it doesn’t matter if I can’t do it. I wander into the patients room, his family are all there, I ask them if they wouldn’t mind stepping out. I happily go about setting up, cheerfully miss my first attempt, tell him I’ll have one more go then I’ll get the anaesthetist…and then I notice the tears streaming down his cheeks.

“I don’t know what happened”, he’s saying, “one minute I was mowing the lawn…”

He stops and looks at me. “I nearly died didn’t I?”

I nod, pull up a chair, and hand him a tissue.

“You’re here now” I tell him, “that’s all that matters really”.

“Life is so short”, more tears stream down his cheek “so short”

We talk. I could almost see his whole world changing before his eyes. Everything he held true evaporating. I repeat that all that matters is that he is here, and that he gets to keep going. I tell his family to come back in. More tears. The cardiology nurse comes in and tells him that his kind of heart attack is known as the widowmaker (yes, we really do refer to it like that!) His family looked stunned, they don’t know what to say. After all, it was like any other day – Dad was just mowing the lawn.

The guy has lots of risk factors. A little bit overweight, drinks on the weekends, smokes a bit, all seemingly benign enough, all completely insidious. I don’t need to point this out. He’s already talking about never smoking again. Watching people come to realise that how their body works is so much more important than how it looks is one of the best parts of my job. No one ever really listens to their doctor. I can tell people how to live and they’ll smoke, drink, and eat too much fat. You have to realise what’s bad for you for yourself.

I get the line into his foot. Less than ideal but it’s a big one and I know the cardiology fellow will be happy. And I know this guy will live. Watching people get to live is the best.

My Ecology

You died. You bloody died! You weren’t supposed to die. You were supposed to be the part of the story where I learn the true magic of modern medicine, the Saving Lives dream come true. But you died.

My history of you begins with the bat phone. It’s really called that. Loud important noises go off, the two way radio gets picked up, the story begins. An electronically transmitted ECG appears on the screen. It’s bad. It’s real bad. My registrar tells me to go to the resus bay and I busy myself setting up stuff to put a line in and get blood. Needles, tubes, alcohol wipes. And then you’re there on a stretcher, eyes wide open, scared. You’re barely moving. You’re talking two words at a time. People are everywhere, fussing with breathing gear, setting up for an ECG, attaching you to monitors. The boss is shouting orders. I shout back that I’ll get a line in. My reg leans in and says “are you sure can do it fast?”. I nod yes. It’s automatic. Immediately I doubt myself, I’ve only tried one line this large before and it was such a horrible painful failure that I never tried again. But this time it’s different. The line goes in immediately.

We push in fluids, the cardiology team arrives, time for you to go upstairs. Upstairs. The magic life saving place that is the cath lab, where truly broken hearts get fixed and where you’re supposed to live. You’re only young. Your wife and daughter appear as you’re being wheeled away. The boss stops the bed moving for a minute so they can have a moment. An eternal moment. I watch from a distance as your wife sinks into a chair and your teenage daughter stands there blankly. And then you’re wheeled away. Wow, I think. Wow. To be a cardiologist must be so amazing, because they’re going to fix that.

We go back to our other patients. Five minutes later the sound of emergency pagers ring out, reaching a collective crescendo. The team leader nurse is already halfway out the door with the portable defibrillator. She shouts at the medical student, the only one free to push the cart. He’s only just started on clinical rotations None of us doctors can help, we’re too busy with the other patients. I watch him obediently follow her up stairs.

We go back to work. Later the team leader appears. “He arrested. He’s tubed now. They’re pushing on with the angio”. Everyone agrees to find out what happened in the morning, it’s time to go home, now past midnight.

I’m at work today. I have a few patients I’m sorting out, mainly elderly people with elderly person problems. I see the cardiology registrar. I ask him. The registrar shrugs and says “oh that guy died”, and walks off.

You weren’t supposed to die.

I go back to work. The wind is out of my sails. For a minute a small voice tells me I want to cry. Another tells me it’s not my journey. Another tells me to get back to work which sounds sensible so I do. Another says nothing and just observes.

“You’ve got to learn to be more lazy”. I look up, and an intern is standing there, handing me a coffee. It’s late. It’s nearly time to go home. “you’ve seen so many patients” she says, “way too many!”

She’s right in a way. I’m not getting out on time. There’s a lot of paperwork left to do but I don’t really mind. I used to mind. I stay back and finish it. I lament my lack of thoroughness for seeing so many. I call consultants to get the patients admitted and give half baked stories but it’s late and they just want to sleep so they accept them.

I get my handbag and walk back to my car. Driving home I notice the other cars on the highway, some big, some small. Lights passing through the night.

You weren’t supposed to die.

…and a time to die.

Recently I was on night shift, eating KFC at 3am in the common room with the other interns and joking about things that shouldn’t be joked about around food, and my pager went off.  I could dedicate a whole post to my pager and one day will, but it will mostly about wanting to throw the thing at the wall.  But this time it was different.

I rang the number, and the nurse of a certain ward answered, and let me know an elderly patient had died, and the family would like me to come up and confirm it.  A lot of the time you’ll go up and confirm it without the family present but this particularly patient’s relatives wanted to be there.  I hung up and started making my way up through the labyrinth of corridors to the ward.

I’d never certified a death before.  When I put my chicken down and told the other interns, I was met with a sombre mood, and “your first?” followed by sympathetic pats and the promise of chocolate on my return.  As I walked through those silent corridors, my heart was pounding.  What would they look like?  How did they die?  What if I got it wrong?  What if I certified them and they weren’t really gone?  What if they had a pacemaker?  All sorts of ghoulish thoughts found their way into my mind and by the time I reached the nurses station, I was a quivering mess.

The nurse on was lovely, she asked me if I was okay, and I whispered that I hadn’t done it before.  “Want me to come with you?” was met by a frenzied nod on my behalf, and I took a deep breath, hung my steth around my neck, and walked into the room to met five grown men and women in tears.  In the bed was the dearest old lady with a pretty neckscarf on, her eyes closed, her face peaceful.

I looked in her eyes, listened to her chest.  She was quiet everywhere.  When I tried to take her pulse, my own heart was beating so hard that I could feel my own through my fingers and I took it for maybe a little too long.

“Are you sure?” came a tiny voice, from a grown man, and I nodded.  I told them I was sorry for their loss, and that I thought she looked beautiful.

Outside the nurse squeezed my hand and I did the paperwork.  Then I went back downstairs where I was met with chocolate and similar stories.  One intern had dreamed about his patient for a week afterward.

I will forever be grateful to my patient.  The family told me she was a lovely and kind woman and I couldn’t help but think that in death she was the same.  My introduction was so gentle by comparison to others, and she (I will never forget her name), has my eternal gratitude.