Mr Smith — in memoriam
Posted on 21 January 2013 by Zoe Greaves
I will never forget the moment I encountered my first dying patient. He was neither the first patient I had seen die, nor the first death I would certify. But he was the first patient in whom I had watched the process of dying.
At 3am, nearing the end of my first medical night shift, I was called to a side-room by the nurses. The patient — we’ll call him Mr Smith — had deteriorated. I stood at the end of the bed to see a frail and cachectic old man with sunken eyes, whose breathing was rapid and shallow. He had bi-lateral pneumonia and despite the best possible care had taken a turn for the worse earlier that night.
I stood at the end of the bed and mentally ran through my ABCDEs — everything medical school taught me that I ought to do. And I baulked at the idea.
I could attempt to take bloods, to site a cannula, to take an ABG and arrange a portable chest X-ray but in truth, with a heart rate of 40 and a BP not much higher, it was not going to change anything and would almost certainly cause pain and distress. Advice from a consultant earlier that week was ringing in my ears: what is this test going to show us, and what will this intervention achieve? Whatever I did, Mr Smith would die.
And so I paused and did what every self-respecting junior does and called the med-reg: ‘I don’t know what to do.’ She assessed Mr Smith, agreed with my conclusion, and started him on the End of Life Care Pathway (my trust’s equivalent of the LCP — Liverpool Care Pathway).
Mr Smith was written up for medication to help his agitated breathing. No family could come so I sat with him for the few minutes before my bleep summoned me again. He died soon after. I was relieved he was spared the additional pain and indignity that extra intervention would certainly have caused in his last hours.
End-of-life pathways have recently come under savage criticism in the press. The LCP in particular has been labelled a ‘death pathway’, a ‘backdoor to euthanasia’, and a way for trusts to save money by emptying beds more quickly.
The LCP is used when the focus of care has shifted from active intervention to palliation and is tailored to the use of the individual, and under constant review when used properly.
From meetings and conversations I’ve had, I believe end-of-life pathways are an important issue for many junior doctors and I think there are two reasons for this.
First, it is said that end-of-life care is always surrounded by emotive issues, which can muddy the waters of debate. When we say ‘emotive’ are we are thinking only of patients and their families and forgetting ourselves?
Professionalism tells us that our thoughts, feelings and emotions must take a back seat to those of our patients and their families — and rightly so — but often we overlook our reactions completely. We forget that our empathy and humanity often make us the best doctors. This is perhaps the elephant in the room; the emotive factor that we must learn to acknowledge and work around if we are to debate end-of-life care with clarity and insight.
I hope we all remember our ‘first dying patient’: the suggestion that we hurried their end for a trust’s financial gain is offensive and hurtful.
Fear is the second reason for junior doctors’ interest in the issue.
What will happen if the public lose their trust in the palliative care provided by doctors? Some say it is beginning to happen already. Will we find ourselves standing at the end of Mr Smith’s bed, with no option but to perform the blood gases, cannulations and catheterisations that other pathways, protocols and guidelines demand of us? Do we fear that, if we don’t, we will be faced with a family accusing us of hastening a loved one’s end?
The government has recently announced a review into how care is provided at the end of life. As a profession, emotion aside, this should not be seen as a criticism but must be welcomed. As in all areas, practice should be reviewed continually to identify areas for improvement ... after all, why else do we audit?
For the gold test, I am certain that if I, or a member of my family, were dying I would want the LCP to be employed in the last hours or days of life. And I would most certainly not want the junior doctors caring for me, or my loved ones, to feel pressurised into delivering futile and distressing interventions or treatments.
Zoe Greaves is a South Tees foundation year 2
*Patient name and identifiable information has been changed
The BMA medical ethics committee strongly supports appropriate use of recognised frameworks for end-of-life care to improve care and support for dying patients and their families. While the review of the LCP is being undertaken, doctors using the LCP may find it helpful to read the Marie Curie Palliative Care Institute position statement and FAQs.
Education and training
end of life issues
medical education and training