Remember tears when you toughen up
Posted on 1 November 2012
I once had a house officer who I found crying in the linen cupboard. We had just put an elderly patient with end-stage renal failure and recurrent bowel cancer on the Liverpool Care Pathway, and this junior doctor was devastated.
During my first year of medicine, I have no idea how many times I wept over difficult cannulae, tiny old ladies who had been widowed, and patients with terminal illnesses, but it was definitely quite a few. It shocked me that my initial reaction to the house officer’s tears was one of surprise.
The patient had a terminal illness, and I felt very strongly that he should be allowed to pass away comfortably and peacefully rather than undergoing painful, invasive and ultimately futile treatments on a noisy ITU.
I love intensive care. In the right situation, it is a genuine wonder to behold. People can be supported through illnesses that would have been unsurvivable even a few years ago. However, for some patients it is absolutely not the right path to take.
It saddened me that I was surprised by the doctor’s tears, because I like to think that I am a caring sort of clinician, and I felt bad for not pre-empting her feelings. Perhaps wrongly, I didn’t think to discuss the decision to start the Liverpool Care Pathway with her beforehand, because the next step seemed so painfully obvious to the rest of the team. Had I become one of ‘those’ doctors?
As she sobbed, I gently explained that this was for the best, and the patient had come to the end of his natural life. She looked up at me with tear-filled eyes and asked: ‘Isn’t there anything we can do?’.
The Liverpool Care Pathway is most certainly ‘doing’ something. It protects patients from unnecessary investigations, and helps to focus our minds on symptom relief and pain control. We are absolutely helping our patients, just in a different way.
Accepting that patients die is a difficult process, and not one that should be underestimated. I think many of us are guilty of giving a quick nod and marching on without really thinking about the emotional consequences for our juniors.
It takes a good few years to develop a registrar rhino hide, and this must not be forgotten. As a junior, you don’t always know what to do. You don’t always understand that death is sometimes the kindest option. We should all be making a point of asking the more junior doctors how they feel about the patients they look after and the situations they encounter.
Every hospital linen cupboard must have hosted hundreds of tearful juniors. Perhaps — with changeover having only just occurred — we could all do more to explain decisions to juniors, and hopefully reserve the cupboards for linen.
Emma Casely is a core trainee 2 in anaesthetics in London
doctors for doctors
end of life issues