Wednesday, 11 July 2007

Death and the maiden

I had a long consultation this morning which I thought was worthwhile. It was with Simon, a young lad in his twenties who has been looking after his kid sister Janie. She developed a particularly nasty form of cancer a few years ago, and despite the best efforts of the hospital the cancer has recurred. From what he says I think that the end cannot be far off. Simon has been more than a big brother, in many ways he has also acted as her father because of the lack of appropriate parental figures in the family. He certainly feels very responsible for her. The problem is that he is in denial. The cancer specialist has told the family that he cannot cure Janie, which is his gentle way of saying that she is not going to survive, but Simon still thinks that treatment will help each relapse and that some new cure will be developed in time to save her.

Janie is not my patient so I only know what Simon tells me, but it sounds like a classic situation with the family in denial and colluding to hide the truth from Janie. This morning Simon told me that he cannot think about Janie dying, he tried to imagine her funeral but could not do so. I have been to this particular place and got the tee-shirt, and I recall the moment when I started to entertain the possibility that my son might die. I was driving home from the hospital at the time and it felt rather like grasping a nettle, a painful thought below the surface. I pulled it out and examined it in an almost disinterested fashion. In time I was able to accept the full reality of the situation. So this morning I asked Simon to try simply considering the possibility that he might lose Janie. It was an odd consultation because we were able to talk about things as theoretical abstracts without admitting that they might exist in reality. I somehow managed to suggest that if Janie were dying he might be using up a lot of energy in denying reality to himself and in hiding the truth from her. And I also suggested that if there were to be only a limited amount of time left it would be better if things could be discussed openly. Simon and I have had a good relationship and I hope that today's consultation was helpful. I shall be seeing him again shortly.

Speaking of death, I've been chatting with Martha about our approach to life in general and work in particular. She came up with the genial idea of considering what might be written on our tombstones. She reckons mine will be “he never promised what he couldn't deliver”, while her own aspiration is “she was never any trouble”. I wouldn't dream of challenging her perceptive insights, but I rather like Spike Milligan's suggestion - “I told you I was ill!” The British Medical Journal will publish the obituary of any doctor associated with the UK, and they are particularly keen to receive obituaries written by the doctor himself (before their death, rather than through a ouija board). I should certainly like to write my own but haven't got around to it yet. If I drop off my perch unexpectedly perhaps Martha will oblige?


The Shrink said...

The Shrink said...
I'm quite taken by Gabriel Garcia Marquez, writing in Love in the Time of Cholera :

"The only regret I will have in dying is if it is not for love."

Calavera said...

Oh, that is so sad...

I've said this before... but sometimes I'm really glad that I'm 'just' a third year medic and not really in the deep end like that... I don't know how I would tell Simon about the reality of Janey's situation... or even if I would...


The Shrink said...

Cal, I've worked in a hospice doing palliative care, hospitals and community doing dementia care, inpatient geriatric medicine, some ITU care, some Tertiary Care burns wards I've worked on, as well as the slew of cancers and other "much badness" that hits folk in medical work.

Surprisingly, as well as getting folk better, helping folk accept bad news and endings (of expectations, of ADLs, of dreams, of life) can be equally rewarding. A good death is perfectly possible and pretty common. As medics we can help people cope with losses, much of our work is just that.

With clinical experience you'll subtly develop these translatable skills of assisting folk in managing loss, then using this to help manage serious loss, including loss of life.

Early days for you, don't sweat that it's as harsh to do as you may fear. Helping folk through dark hours can be appropriate and rewarding work, too, but comes with a degree of experience to "be there with them" in such difficult times.

Anonymous said...

I too do not know how you begin to explain to anyone they are about to loose a loved one. I admire all of you in the medical profession and what a tough job you have. Thanks doc and the shrink for letting us know how you deal with it.

Dr Andrew Brown said...

Cal: The Shrink is quite right - it's a skill that you will learn (if you wish to). Learning to deal with people well is just as much a skill as doing an appendicectomy, and presumably you're not doing those unsupervised just yet? :-)
Partly you will pick it up by watching experienced doctors, you should also get some formal tuition. What you are trying to develop is empathy ("I understand this must be hard for you") rather than sympathy ("I feel your pain"). You also need insight, humility and compassion. This can't happen overnight, but training as a doctor will help you develop very quickly. Your postings suggest that you have lots of potential. If you can do this right then your patients will think you are a "good doctor" - and what higher accolade can you hope for?

A. said...

Do you think sometimes that the denial is combined with a communication mis-match? I remember when both my mother-in-law and father-in-law died, my husband had telephone calls which he totally misinterpreted, and was horrified when each of them died very shortly afterwards.

My husband is a fairly bluntly spoken person and when people put things to him tactfully/obliquely he just doesn't see what they are getting at.

I'm much more inclined to look behind the words, but I do recall coming round from an anaesthetic once and being asked if I had any discomfort. I wondered what on earth they were talking about. Who cares about what the pillow is like when you're in agonising pain? So I answered no.

Dr Andrew Brown said...

A.: You make some excellent points and I'm sure you are right. Sometimes we professionals "beat about the bush" thinking that we are being helpful. I had a similar experience when my son was seriously ill. I know that when nurses ring relatives at home they are not allowed to say that the patient has died. I had seen my son late the previous night and thought it likely that he would not live. The next morning I received a call and the conversation was along the following lines:

Nurse: "Can you come to the hospital please, he has taken a turn for the worse."
Me: "Are you talking in hospital-speak?"
Nurse: "Yes."
Me: "Thank you. We'll be in later."

I was most grateful to that nurse for her honesty. Like many patients, I wanted to know the truth so I could make the best arrangements for me and my family. We grieved together in private, and then prepared ourselves to go to the hospital.