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.

 

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One comment

  1. Your post is exactly the inner-thoughts I like to think the nurses had when they looked after my father in his last days. My Mother, siblings and I knew they were doing their best to ensure Dad had a pain-free and dignified end. It’s your post which has helped me truly understand what I couldn’t acknowledge at the time; there was really nothing more they could do. I prayed and hoped for a miracle, and they did what they could in the real world. So they offered Dad a wine with dinner and gave him two serves of ice-cream when he couldn’t eat the main meal. They were the best carers he could have had and I just want to wish you all the best in your career.

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