Difficult conversations

The theme of today’s blog is difficult conversations. The life of a doctor is full of difficult conversations, whether that is discussing do not attempt resuscitation orders with patients, explaining to a family that their loved one will likely die on this admission, or explaining to your loved ones why you have to miss another family occasion.

I will focus on a conversation that happened three weeks ago; regular readers might recognise the scenario. The situation occurred around 4am, whilst I was on a night shift. I was called to see a hypothermic patient, who shall be called Hannah for this post, which I expected to be a simple case prior to seeing the patient. However, when I arrived Hannah was acutely unwell and dying. I hurriedly tried to intervene with blood tests, cannulas and giving IV fluids. I called for help from my seniors shortly after stabilising the patient. Hannah continued to deteriorate and the medical team decided that the patient was likely to die and further intervention would be futile, causing more suffering than good. We thus made the difficult decision to change our approach from active management to palliative, comfort care. This scenario was personally very difficult for me for a number of reasons, for which I will not delve into just now. If you want to read more about the scenario I will link the blog post here.

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Once we had decided to palliate the patient at around 6am, the ward nurses desperately tried to contact Hannah’s next of kin without success. Eventually, we contacted the police to bring the patient’s sister to the hospital so that we could inform them about Hannah’s deterioration overnight. I wanted to tell her sister about the events that had unfolded overnight and give an update on the sombre circumstances that Hannah was in.

The conversation took place in a small room, with one 2-person sofa and a single armchair in it. The patient’s sister – let’s call her Mary for this blog post – was sitting on the sofa with the nurse in charge sat close by for emotional support. I was sitting in the armchair with my senior colleague standing next to me for my support. The room was comically small but it was all that we had to offer. I was weary after a long and hard night but I wanted to get the conversation right. Drawing on my previous experience working within a palliative care unit in my previous job, I knew that I needed to present the facts in a direct manner, whilst being supportive and sensitive. It is quite a delicate balance presenting medical opinion in a matter of fact manner, so that the overall message cannot be misconstrued, yet not sounding crass whilst doing so. For this reason we are taught not to use phrases such as “passing away” or “no longer with us”, and instead replace these euphemisms with medical terminology such as “death” and “dying”.

I proceeded to ask Mary about her opinion of Hannah’s situation so that I could gauge how much she understood. She understood that Hannah was unwell but told me that she was always in and out of hospital. I used that as a foundation to explain the unfortunate situation that had occurred overnight, outlying our investigation findings and how we had tried, without success, to treat Hannah. I then proceeded to explain that the patient was unlikely to survive this admission and that she would most likely die within the coming hours to days, given the rapid speed of deterioration overnight. I carefully controlled the tempo and tone of my words, delicately constructing each sentence prior to delivering the news. I paused often to ensure that Mary was still following. However, within minutes I realised that she was not taking much in. Mary went off on tangents at each pause, about how she did Hannah’s shopping and cooking, all whilst smiling. I noted her odd comments at each interlude and gently tried to steer the conversation back to the dire situation at hand.

About twenty minutes into the conversation I felt that the messages that I wished to convey had not got through to Mary. Maybe she didn’t understand the situation, or maybe she refused to understand? Maybe I had not delivered the message effectively? I was rather frustrated and my senior colleague spoke up to reinforce the message that Hannah was very likely to die soon, yet still Mary proceeded with some nostalgic tangent. About half an hour into the conversation I had completely given up hope of getting anything across to Mary and decided that perhaps she might like to spend time with her sister. As I was preparing to round up the conversation I asked Mary if she had any final questions. She did. “So will the coronavirus situation at the moment affect the funeral arrangements for Hannah?”

I was a bit struck by the question. It showed a level of insight from Mary that I didn’t expect. All along I thought Mary didn’t understand Hannah’s imminent mortality and was clueless about the situation. In fact, we as the medical team didn’t understand the situation. We were the clueless ones. Mary and Hannah lived a few hundred yards apart on the same street, and Mary had cared for Hannah through all of her hospital admissions over the years. Mary knew Hannah better than anyone else in the world, and our medical team, having known Hannah for two or so hours, thought that we knew better. We were simply mistaken.

It seems that Mary had been preparing for Hannah’s death for some time and had a level of appreciation for the gravity of Hannah’s state that surpassed the medical team’s ‘expert’ opinion. If we had included Mary in the discussion about Hannah’s care earlier in her admission we may have focused on comfort care sooner and saved Hannah from those stressful and invasive interventions during the early hours of Monday morning. We may have given her a better and more peaceful death. Hannah died later that day, around midday, with Mary by her bedside.

As medical practitioners we must strive to understand our patients and I believe we often do a good job of this. We understand their medical issues, both present and past, we learn about patients’ social and living situations and we determine their wishes about treatments. Yet we sometimes neglect the patient’s family and the insight that they can offer about their loved ones. They are an untapped source of knowledge that can help direct patient care when patients are at their most vulnerable. We often wait until the last minute before consulting families of vulnerable patients, but should we doing so much sooner? I think so.

A coronavirus update from Edinburgh

We are seemingly past the peak of the coronavirus pandemic in Scotland for now. Even so, there is still substantial risk of a second wave of COVID patients and for this reason we are still under a strict government lockdown. Small businesses are operating from home, and if they unable to work from home, workers are on government furlough schemes. There have been minor regulation changes in England allowing more freedom of movement, but those liberties have not yet been granted in Scotland. In hospitals in Edinburgh, COVID admissions have dropped dramatically, into single digit admissions each day. Last time I looked there were only three COVID-positive patients in the intensive care unit. Some services are starting to return to normality. We are starting to operate electively in greater numbers and life for us on surgical wards is returning to normal. I am hopeful that the number of COVID patients will continue to fall and that soon we might be allowed those additional liberties that our English neighbours are currently enjoying.

More One Doc’s Stories:

P.S. Please comment below or message me on the “Contact” page, I’d love to hear from you!

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