Goodbye

Today I want to write about two deaths. One was good, the other less so; yet perhaps not as bad as it appeared at first sight.

This afternoon I visited a very elderly man in a nursing home. He had been deteriorating slowly for some time and at his request we had given up active treatment and were just keeping him comfortable. His wife was always present whenever I visited, cheerful and caring. She asked me to visit today because she thought he was chesty, although the nurses were not convinced. He looked very poorly with sunken eyes and dry tongue, panting with a fast respiratory rate, yet he was not distressed. There was reduced air entry and bronchial breathing at the base of his right lung. I could hardly hear what he said, but he clearly recognised me and approved of my suggestion that he needed to drink more. Both wife and son were present and I had a word with them outside his room. I told his wife that he had pneumonia and this might well be his last illness, but that it was known as the “old man's friend” because it is not a bad way to go and there is usually no suffering. She was expecting the news and had a little cry. I told her how much I admired the way she had looked after him, and as usual I could not quite keep the emotion out of my voice at that moment. She and her son looked satisfied with the consultation. Her husband died peacefully three hours later.

I wish that all my patients met their end in such a fashion, but another recent death was less comfortable. A woman of my age came to see me because she was upset after her partner had walked out. I had been her GP for over twenty years, during which time she had suffered a series of losses and setbacks. Most of these were related to men letting her down, either by dying or leaving her unsupported in some other way. I had forgotten until I reviewed her notes after her death just how much we had been through. Of course I hadn't actually done very much, just listened and occasionally prescribed something or referred her somewhere. You know, the usual GP stuff. But I imagine it may have been a relationship she valued because she almost never consulted anyone else in the practice. In retrospect, although I could not offer her much, at least I never left her.

So, as I said, she came to tell me that he had walked out. I don't necessarily blame him. Perhaps he couldn't cope with her emotional demands. The advantage of being a GP is that you only have to see your patients for short periods, and although I sympathised with her and liked her, I did sometimes find that she made me gloomy. Fortunately I don't have to form any judgement, and can simply look at things from her point of view. It had clearly got her down. The clever people who write guidelines say that we should assess depressed people with a validated questionnaire, and the Government insist that we do so on pain of losing income. Her score suggested she was mildly depressed with no suicidal tendencies. So much for the value of validated questionnaires. She told me that she was getting some counselling from the hospital clinic she attended, so I prescribed her a course of antidepressant and asked her to come and see me again two weeks later. On the second occasion she told me that she was a little better and the counselling was proving quite helpful. I said that I was pleased and asked her to see me again in two weeks. Three days later she hung herself.

I discussed her death with my partners as a “significant event”. I felt that I had let her down, first by not realising that she was suicidal, and secondly by not giving her enough hope. Even if you admit people to hospital they may still kill themselves, and ultimately the only way to prevent suicide is to give some hope that things will get better. It is well known that people often visit their GP just before they commit suicide, and the implication is that if only the GP were on the ball he would be able to prevent it. It seemed that I had failed my patient in our most important consultation. Why had she come to see me, if not for me to give hope and save her life? Such were the bad feelings I took to the meeting. There have been many changes in the practice recently and I now find myself surrounded by quite a few young partners. I am constantly surprised by how knowledgeable, helpful and supportive they are, and they did not let me down on this occasion. One pointed out that people who really want to kill themselves can be devious and hide their intentions, and told a helpful anecdote about a consultant psychiatrist who had been completely fooled in this way. But it was another young partner, generally reluctant to say very much, who came up with a profound and extremely comforting insight.

“I think” he said, “she just came to say goodbye”.

Failure

Recently we cleared out the loft to prepare for the installation of a respectable amount of insulation, and this weekend I have been sorting through the clutter that we brought down. Among the junk I found a letter from my mother reassuring me when I felt overwhelmed at the start of my medical house job. Thanks, Mum. I also found the notes I made about my clinical experience in the early years as a doctor. It has been fascinating looking back across nearly thirty years, watching the doctor at work who eventually became the doctor I am today. He seems vaguely familiar, somehow...

Then I found a copy of the medical school magazine from when I was a final year student. There is an article from an academic surgeon entitled “why you lose at diagnosis”. He runs through some very salient reasons. Medical students and tyro doctors often don't ask the right questions, or ask leading questions, or misread the answers. Then they don't play the odds, failing to remember that common things are common. Or they don't know which things are in fact common. They may suffer from information overload, and not be able to see the wood for the trees. They may then fail to make an effective decision, or ignore the consequences of error (what is now known as “safety-netting”). He concludes by advising his readers to aim, not at perfect diagnoses but at winning decisions.

So far so good, but what really caught my eye was his last point: being unable to come to terms with the consequences of error. He wrote: “from time to time your own ignorance, or sheer stupidity, is going to result in decisions which harm patients or even lead to their deaths. But in clinical medicine this fact has to be faced, because you can't be right all the time. So somehow you have got to get used to the proposition that the decisions you make will occasionally have unhappy consequences, and you've got to strike a happy medium between callousness and the sort of emotional claptrap which passes for medical television series.”

That is how they used to talk thirty years ago. I doubt that such an article would be published today with its paternalistic attitude. Yet the advice was well meant, although the fear of harming a patient through my own inadequacy has haunted my clinical career these past three decades. I have either been very lucky, or careful (or possibly both) but I can only recall two occasions on which my sins of omission have caused serious harm to a patient. The first happened right at the start of my career, just a few weeks into my first house job, and I recorded the details in my log. A woman of 70 became short of breath with fever and tachycardia the day after her operation. I initially thought she had a chest infection but she deteriorated over several hours. The medical Registrar came and diagnosed supraventricular tachycardia, but despite his treatment she went into cardiogenic shock and arrested. I wrote “despite resus, crashed into asystole. Had to tell husband. I was really distressed myself afterwards.” No senior doctor spoke to me about it afterwards, of course. To this day I don't know whether she would have survived if the diagnosis had been made a few hours earlier.

To the best of my knowledge I did alright for the next thirty years, but came a cropper again earlier this year. A chap just a few years younger than me had developed a heart condition which was causing palpitations, and had an internal defibrillator fitted last year. Earlier this year I saw him several times trying to sort out his palpitations, and he gradually developed fatigue and breathlessness as well. This came on slowly at first, but then he began to lose weight. I was beginning to get seriously worried about him and ordered a number of blood tests and a chest X-ray, but before I got the results his wife became desperate and rang for an ambulance.

Have you made the diagnosis yet? He had subacute bacterial endocarditis (SBE) and went through a very stormy time in hospital where the two infected heart valves were replaced. The good news is that he has made an excellent recovery with no residual problems. But I felt very bad about the delay in diagnosis. Where did I go wrong?

Firstly I assumed his early symptoms were due to his underlying heart disease. Then I thought that he might have developed some new illness unrelated to his cardiac problems. In fact, when new symptoms arise they are much more likely to be due to an existing condition than a new one. In addition, I did not know that cardiac catheterisation (for angiography or the insertion of pacemakers or defibrillators) is a common cause of SBE. The annoying thing is that the diagnosis had gone through my mind. I listened to his heart and heard a mild “ejection” murmur. I discounted this because I thought that endocarditis would cause a loud, harsh “pansystolic” murmur, and his murmur had in fact been noted by the cardiologists the previous year. I have discussed this at a “significant event” meeting with my partners, who were very supportive. They pointed out that I was aware that there was a problem and I was taking steps to investigate it. The problem was that this illness develops insidiously over weeks or months. Usually in general practice we recognise when somebody is seriously ill and send them into hospital, even though we may not know the diagnosis. The last time I saw my patient before he went into hospital he did not look ill enough to require admission.

Nevertheless I still see this as a failure. I feel that I let my patient down and it has shaken me. Fortunately his wife has been very good about it. She expressed her feelings that her husband had been let down, and I was able to have an open discussion with her in which I expressed my feelings of failure but explained what had happened and where I had gone wrong. Luckily I have known her for many years and there was “money in the bank” which allowed her to accept my explanation and apology. Recently she came with her husband to see me for the first time since he was discharged, and they both looked very happy.

Of course there may have been other cock-ups over the past three decades which I have either forgotten or never knew about. But I don't think my record is too bad. And that's just as well, because I have found causing a patient harm to be extremely distressing. I have never “got used to the proposition that the decisions you make will occasionally have unhappy consequences” and I'm not sure whether I should try. But I still wonder, as I walk into work on a Monday morning, whether I am clever enough for all this.

My chap

Last week I was unexpectedly moved while filling in a complex legal form. An elderly couple had come to see me. She was in the early stages of dementia and he was applying for Lasting Power of Attorney. My rôle was to certify that she understood what this meant, and that she was not being coerced. This job was made harder because her dementia was moderately advanced, and because she was in denial about the diagnosis.

So I asked “if you became very ill and couldn't make decisions about your treatment, would you be happy for your husband to make those decisions for you?” She replied “yes”. I continued “and if your memory got very bad and you could no longer make decisions about your finances or looking after yourself, would you be happy for him to make those for you?” “It's very unlikely” she said, “but yes I would”. “You trust him, then?” I asked. “Oh yes” she replied, “we've been together for...” But her memory failed her, and she could not say how long. She turned to him with a little smile, and reached out for his hand. “He's...” and she paused as she searched for the not-quite-right word, “...my chap”.

I signed the form.

An education

I was clearing out the spare room this weekend and came across the paediatrics textbook I used over thirty years ago. One of the consultants was a bit of a character, and I made a note of a few of his sayings inside the book. Since I cannot find his obituary on BMJ.com I think he must still be alive, which is a cheering thought. I thought you might appreciate this flavour of medical education three decades ago. We were well aware that his tongue was frequently in his cheek.

• (To a baby.) You know the rules, you can't wee on consultants.
• No baby is allowed to die without antibiotics, christening and cortisone.
• (Of drug companies offering sponsorship.) I suppose if you're very poor you have to take anybody's money, but otherwise you ought to be able to tell them to f*** off.
• Seeing this is enough to make Matron's knickers fall down. And when that happens, all you can say is “get them on”.
• Babies and women. Do you think they're human?
• Do try only to kill people on purpose.
• How many times do you make bad mistakes? Several every day? I only hope that when I'm nobbled I'm in the right and not in the wrong.
• Don't you think you've had enough for one day? It's my drinking hour.

 Ah, those were the days!

A plan

Today I was asked to see one of my patients by a Government official who had just interviewed her. The message was that she was “suicidal, and had a plan”.

Now I am all in favour of Government officials being given training in dealing with potentially suicidal people. And it is true that if someone tells you that they have thought out how they are going to kill themselves then you need to take that very seriously, particularly if they have already taken steps to put their plan into action. But I suspect that “having a plan” will soon enter the popular consciousness as being an integral part of feeling suicidal. Just as all flu is now “man flu” (in men, at least) and all vomiting is projectile, so suicidal feeling will be totally unimpressive without a plan in tow.

“Projectile” vomiting used to be a term applied by doctors only to young babies with pyloric stenosis. In this condition the baby will drink a bottle of milk happily (nay ravenously) but then project the milk an astoundingly long way across the room, in the manner of Regan in The Exorcist. That is what a doctor means by “projectile vomiting”. But over many years parents have been trained by keen young paediatricians asking them whether their baby's vomiting was projectile, so that now there is a general understanding that doctors are interested in the projectility of vomit. Since patients so often want to please their doctors they will proudly announce that their vomiting is projectile. And let's face it, you're a bit of a wimp if it isn't.

A long time ago I worked for a commercial out-of-hours service and spent many happy antisocial hours driving around the less salubrious areas of town seeing a series of snotty children and coughing adults. Or occasionally the other way around. When the call details were passed through a very high proportion of the patients were said to have “difficulty in breathing”, but when I arrived their respiration was almost always normal, or at least unlaboured. The reason was that the call handlers always asked the stock question “do you/they have difficulty in breathing?” The customers, perhaps thinking that a doctor would be impressed by such difficulty and might turn up earlier, or fearing that he might not turn up without it, would answer “yes”. This has entered the local folk memory, and even now patients will report difficulty in breathing as a way of seeking my favour.

So I rang my patient who said she was fine, that the official had misunderstood, and she was perfectly happy. Just then her friend grabbed the phone and said “no she's not, she's suicidal”. “No, I'm fine” came a voice in the background. It reminded me of the “bring out your dead scene” in Monty Python and the Holy Grail. (“I'm not dead, I'm getting better!”) I was not convinced that my patient wished to die immediately, particularly when she discussed some of her (non-suicidal) plans for the future, and I made some practical suggestions to give her some hope that things might improve. Which, ultimately, is all you can do for people who see no future for themselves.

Warm room

Ladies and gentlemen, I present the “warm room” sign.

Last month I saw a woman in her sixties who had come for her annual hypertension review. As she walked in she mentioned that my room was cooler than the waiting room, and said “that's nice”. I didn't think anything of it at first, but while checking her blood pressure I noticed that her heart was beating rapidly and her pulse was 108. This was particularly unusual because one of her drugs was a beta-blocker which would tend to slow the heart. I was starting to suspect that she might have an over-active thyroid, and in response to my questions she told me that she had noticed her hands trembling a little and had lost a little weight. I sent off blood tests which duly confirmed that she has hyperthyroidism.

A little later in the month I saw a woman in her fifties who complained mainly of aching shoulders, but had also lost some weight. She also mentioned that my consulting room was too hot. When I examined her I found her pulse was slightly raised at 92 and she also had a slight tremor. Blood tests have now confirmed that she also has hyperthyroidism, though not as severe as that of the first woman.

I like my room to be comfortably warm, not too hot and not too cold, and go to some trouble to make it so. Patients who complain about the temperature may therefore have a problem with their thyroid. It's certainly worth considering.

Death

Yesterday I visited two patients around the age of 90 who both spoke to me of being ready for death. They were not suffering unbearably, but their faculties were failing and they were finding their lives irksome. On returning home I read a book review in the BMJ discussing death, which suggests that we need to accept it in order to live a fully human life. Somehow it gives life its worth - for immortality would be intolerable. And I am currently reading a theological book which describes how one of the purposes of religion is to let us step outside our mundane existence and come to terms with suffering and death. As I am now nearer the end of my life than the beginning, I wonder whether part of my value to patients is to present and interpret this sort of truth to them. I certainly feel that this is a more worthwhile use of my time than doing bean-counting audits.

One of those two patients was a charming and courteous Welsh gentleman living in a residential home. I found it a joy to talk to him, and as I left I said "you're the nicest Welshman I know". "You don't know very many" he replied.