"Doctor! Doctor! Will I die?"
"Yes, my dear, and so will I!"I've been pretty fortunate thusfar in my training that I haven't really come into much contact with the kind of specialities where people have long drawn out deaths - oncology, haematology, renal, and so on. No, most of the deaths I've been involved with have been pretty quick - "sudden arrests" (if there is such a thing in a hospital setting - something I may return to in the future), and at the very most deaths which have occured over a couple of days at the longest.
I can deal with these, they don't really get to me that much (well, not any more). The patient is zonked out, it's all over with reasonably quickly. I can cope with relatives. I can sit with them, explain that their husband, mother, brother, wife is going to die, comfort them, be there for them. I can stand and look at them sympathetically while someone utters those inescapable words - "We did all we could".
One thing I'm not very good at is dealing with those patients who are terminally ill, but in no immediate danger of dying. As I said, I don't see many of these. Maybe 2-3 a year. One such case was about a year ago, when I was on a ward. A patient was diagnosed with a particularly aggressive oesophegeal cancer. The consultant sat with him and his family, and talked a lot about "palliative chemotherapy" and "symptomatic relief" and "doing our very best for you". Of course they didn't really understand - they had no idea what was being said. I think that over the next couple of days it gradually dawned on my patient what was going on.
"Nurse, am I dying?"
Now, what to say?
I could dodge the question. Say I'll get the doctor or the staff nurse to speak to him. Trouble is, that as soon as he sees that I've taken the premise of the question seriously enough to do that, he'll know the answer, and then be left laying there with his imagination running wild, and be virtually helpless through fear by the time somebody does talk to him.
I could stall for time. "What makes you think that, Mr Smith?", or "Aren't we all?". But really, what's the use? He needs this question answering, and he's not going to settle until he gets an answer.
I could answer him. That's what he wants, what he needs. But should I? I would, but I tell myself that it's not really my place. That's a standard thought for anything which nurses don't feel comfortable doing, and end up dumping on a doctor. But what's really stopping me? After all, he knows me, and I know him - I could get a doctor to do it, but it would be just some faceless SHO who's never met him before, and probably never heard of him before reading the notes. In some ways, I'd be the best person to do it. But I don't.
Of course, the real reason I don't do it is that I don't know how. How do you tell somebody that they're dying? I could tell their wife, their son - no problem. But how do you look somebody in the eye, and say "yes, you're going to die"? You run it through your mind a million times, trying to make it sound somehow better, less distressing. But at the end of all that deliberation, you have to accept that death has an unescapable capacity for misery, and that all that is left is to deliver the news quickly.
One of the best bits of communication I've ever seen was from a senior registrar, with a patient who was rapidly heading along the line from breathlessness to respiratory arrest to intubation to death. "YOU ARE GOING TO DIE, VERY SOON. WE NEED YOUR PERMISSION TO PUT A TUBE DOWN YOUR THROAT TO HELP YOU BREATHE, RIGHT NOW". At the time, I stood at the side of this patient, who was naked (in the process of being catheterised and having an ECG), and about as short of breath as I see people come, absolutely dumbstruck. I couldn't believe he'd just done that. I thought back to the endless lectures on "communication skills", where lectures talked about sitting in a nice neutral setting, square on, perhaps with a reassuring hand on their knee or a sympathetic smile, breaking the news gently. What a load of codswallop. This woman needed to know, and quickly. There was no point dressing it up. Over time I came to realise that.
And so it was with my oesophogeal cancer patient. I'm sorry to say I let him down terribly. I hope next time I'll have the guts to do the best for my patient, rather than what makes me the least uncomfortable.
3 comments:
I had an arguement... well, no. That makes it sound violent. I had a measured debate with my old mentor about telling patients about dying. One of our patients had been for a test, and carcinoma-riddled tissue had been found. This patient had been asking after the results for this test. In this case there were specific orders for the family to be present at the revealing of any important news, as the patient was quite elderly and not, apparently, able to take this news on their own. So my mentor dodged the question, effectively lying about the results. When I, full of pith and idealism, questioned my mentor on this, I was told that RCN mandates aside, we firstly had an agreement with the family and secondly were not Doctors. Apart from the presence of carcinoma, we knew little else about the results. I think this is a solid piece of reasoning, although whereas this patient had years, hopefully, left of life, this ideology can hardly be applied to someone quickly deteriorating.
I feel very uneasy about these agreements with the family. They are often made with the best of intentions, but are, IMHO, fundamentally flawed. I think you have to remember that it's the patient's diagnosis, not the family's, and (unconscious/delerious patients aside) they have the right to determine who receives that information. I know that I, for one, would want to know before my family. A lot of patients, in my experience, have been quite upset that their family have known before they have.
All this aside, there is the argument about waiting until all the facts are known. In your case, it wouldn't have been good to say "Yes, you have cancer" but then not have any information on prognosis, treatment options, disease progression and so on. I think in that setting I'd have no qualms about a little white lie such as "We're waiting for the test results to arrive".
The problem is that sometimes there is a set plan for the breaking of bad news. One of the things that makes the area of death such a difficult case is both the taboo of not openly talking about death and the sensitivity of the information.
The best way to deal with the patient with terminal illness (as paliative care is also a part of Nursing where the subject comes up, especially in acute medicine) is to find out what that plan is from the medical team as to how the news will be broken and when. Another problem is when you have to speak with the relatives of a dying patient and they ask you how long they have left. The true answer is it is nigh impossible to say with any degree of certainty. It is foolhardy to guess either:- quote too short a time and you can give false hope, too long and you risk upset.
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