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.