Tuesday, 27 July 2010

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”.

16 comments:

The Girl said...

That is a great post. I often wonder how I would take it if a patient of mine took their own life. I really like the way you dealt with it, and your colleagues sound like top notch people.

Thanks for sharing.

Dr Andrew Brown said...

TG: thanks very much for your kind comments. As you said in your recent post, you need friends to get through medical school, and you need good colleagues to get you through your life as a doctor. This is particularly true in general practice where, as The Shrink pointed out recently, you are professionally isolated. Your partners should be your colleagues and your friends. Indeed, with the long nature of the relationship and the financial inter-dependence, partnership has been described as a marriage. Of course there are dysfunctional partnerships as well as dysfunctional marriages, but on the whole I've been lucky (in both of these aspects of my life!)

A New Kind of GP said...

Dear Dr Brown
What a powerful thought provoking piece you wrote!

I wonder if while writing this you had(as I had) read Dr Alys Cole-King's perceptive "Personal View" in last week's BMJ (BMJ 2010;341:c3890)? If not, then you definitely ought to.

Her paper eloquently describes the conflicts inflicted on front-line staff in the health service and how these have caused a move away from a patient-centred approach. She describes how there needs to be a move away from "risk management" (where there is a focus on eliminating risk) to "risk mitigation" and that there needs to be a recognition of how doctors (GPs and hospital doctors) are so highly trained in using their clinical skills to deal with clinical complexity.
She describes how the current culture causes many to be "reluctant to enquire too deply into a patient's suicidal ideation in case they idetnify a risk that they then feel unable to 'eliminate'."

"Lives are not saved by completing suicide risk assessment forms and ticking the box to show that the correct procedure has been followed."

I think you did well.

fatmagülün suçu ne said...

thank you

Anonymous said...

Thank you for your honesty and humanity which is so evident in this post in particular. We are all vulnerable and I do hope you have continued support in what you do. It's so important to be able to talk and gain insights from colleagues.

Anonymous said...

As a long term sufferer from depression I think your young colleague was probably right. And amongst all the political chaos around the NHS right now, thank you for a blog post that brings it back down to what should matter - the relationship between doctor and patient.

Doctor Jest said...

Your young partner is probably right.

And so much for the bl**dy PHQ9. We both know however "validated" it is there's a significant difference between depression and hopelessness that no ammount of testing will uncover.

It's always tough to be reminded there are some things we just can't fix. The trick is to keep on trying, but then you already knew that.

Dr Genesis said...

I am so glad you have taken up your blog again. I find it very comforting to read, as I wade through the tides of general practice. Please keep writing.

intothesystem said...

This is a lovely post.

I think your colleague may be right too. Before my last suicide attempt I went to see my lovely GP and that too was mainly to say goodbye. There was nothing he could have done to have stopped that attempt, although he tried his best. I failed and I guess for him that is fortunate, but you were not so lucky.

I also echo the thoughts on the PHQ9. It's pretty useless, especially if the patient has seen it many times before. I know exactly what answers get what score, so if I felt so inclined to minimise my risk I could.

Lancelot Gobbo said...

Decades ago I was doing the psychiatry segment of my vocational training scheme in London. Two patients suicided one weekend and I found out on the Monday morning. By Wednesday I had shingles, which illustrates rather well, if anecdotally, the relationship between mood and immunity. My consultant said rather gruffly that I would have to appear at the inquests and that everything would be alright. There was nothing else said or done, until I found that the two coroners offered me more consolation and kind words for my efforts to help these two individuals than anyone else ever did. Up to that point I had rather felt that I should make sure things come in threes. A loathsome experience.

soubriquet said...

I came to this blog by a link from I know not where.
This post took me back to a day long ago when I, at my wits' end, went to see my GP, to ask for some help in sleeping.
He asked why I wasn't sleeping, and I fell apart, sobbing, unable to speak.
I told him. There was a manhunt, a murder enquiry. The police had searched my house five times, the last time, somewhat destructively. They seemed angry, as though they were sure if they searched well enough, they'd find the evidence that they needed to prove my guilt. As if they "knew" I was guilty. even now, nine years later, I'm shaking, just thinking of it.
I was sure that, for whatever reason, the commanding officer had decided I was guilty, and that I was facing a future as a convicted murderer behind bars.
Despite the fact that I'm a nonviolent person, with no connection whatsoever to the crime, merely that I lived alone, near where the person disappeared and I had no alibi.
My GP listened, let me cry, asked his colleagues to take his patients for a while.
I was sobbing "I'm sorry, I'm taking up your time, I'd better go", and he called the receptionist and asked her to bring tea.
He didn't know that my turmoil centred around when and how to kill myself. That I could not face being locked up for a crime I did not do, and I would die rather than be framed. ~But his words and actions that day helped to pull me back from the brink, that chance to speak, to let out all my fears, to cry as I have not done since I was a child.
When, eventually, I left, I felt I could go on, for a while anyway, and yes, I think he saved my life. Without drugs, just by letting me fall apart, without seeming to judge me, and by helping me remember the good things in life.
Perhaps if the real murderer had not been found, shortly afterward, I might have jumped from a high place. But that would not have been any fault of his. Nor, I fear, did I tell him how constantly suicide was on my mind.

I'm still grateful. You can't save us all, and you'll never truly know how many you have called back from the edge.
It is certain that some have been to you and been saved without you knowing.

My advice, as a sometime suicidal patient is this - let them talk, make time, don't look constantly at your watch. Don't throw them out, when they fall silent, or weep.

Take my thanks, as one of those who was saved.

Edwin said...

this is really touching story..brought tears in my eyes...thanks for posting

Carla said...

Hello Dr Andrew Brown:

My name is Carla, I study medicine in Chile and I would like to know how to help patients and how to be assertive when talking about their death.
Since some diseases such period is long terminal and it is necessary to provide palliative patients cares.
I really liked the theme of this post
because it speaks of a very common
in the lives of doctors. It's more humanitarian side scientific side that should be our career.

I would appreciate to give me her opinion on how to handle such situations

Thank you very much!
I wait yor answer so anxious

Janeway said...

Doc,
This is very much behind time but you might find this interesting, on the underlying theme in your post of the relationship between doctors and their patients:

http://www.nytimes.com/2011/04/02/health/02resident.html

(sorry about posting it here - no email to send it to)

Nurse and Hospital Stories said...

Ah, two deaths yet so different. The one is a happy one and the other, a bit tragic. That latter patient should had visit a psychiatrist, eh. These two stories, seemed to tell me that while still living, I must enjoy every moment of my precious life as well as pray for a happy death. :)

Thanks,
Peny@medical uniforms

The Angry Medic said...

Hey, it's me; I used to blog back in the early days of you blogging. If you ever start blogging again, drop by and I'll give you a shout-out. Sorry to see you go and take care.