Today I have to talk to three of my patients about dying. This is how I do it
It’s 9.15am. The medical team is full of energy and caffeine. We have patients to see, some of whom are on the road to recovery, others who have already been recognised as dying, and some who have uncertain futures. There are three new patients whose condition could worsen at any time. Given their frailty I believe cardiopulmonary resuscitation (CPR) would be futile. It is now my job to start a discussion about their future care. Three conversations. I take a deep breath.
The trainee doctors are attentive and still learning how to do this. I complete my assessment for the first patient, pause, then open the discussion. My version is not perfect, and it varies. If it does not vary then it shows I am just repeating some learned lines – an impression that is important to avoid.
I open the patient’s mind to the possibility of dying (be it suddenly or gradually). Their next of kin may be present. Each patient reacts in their own way. A faraway look is not uncommon. Sometimes a film develops over the eyes, glistening in the light of the nearby window. Poetry has no place here, but as a human, I am affected by the impact of my words.
This patient and I reach an understanding – we agree – that CPR is not the right thing to do if their heart stops. If either they or a relative had disagreed, we would park it, and arrange to speak about it again later. Now I walk away, unsure how to close the interaction. A hand on the arm, a swish of the curtain? There is no comfortable way, to be
honest.
Outside the bay we complete the ‘Do not attempt CPR (DNACPR)’ form to make it official, for the benefit of others who might be called to see the patient in an emergency.
For the next patient, we review their history and agree we need to anticipate the worst, even if – fingers crossed – it doesn’t happen during this admission.
I use subtly different words, but move in the same direction. This time there is a more overt reaction, and a longer discussion. The thought of dying has never crossed her mind. Nor her husband’s. Part of me brims with anger: she has an incurable, gradually worsening condition, and has been seen by her GP and in specialist clinics umpteen times over the past year. Why has no one brought this up? Why does it have to be me? I could just leave it. She might not deteriorate after all. Why not leave it until she does?
But if that happens at 3am, and a foundation year doctor is asked to see her, and they refer to a registrar who has never met the patient, there will be hurried decision-making; the patient will probably not be conscious enough to express their wishes; an ICU consultant will be asked to make a call based on scant information. It’s bad medicine, just like the cases reviewed by national confidential enquiry into patient outcome and death: of 198 patients who, in the opinion of an expert panel, should have had a DNACPR decision, only 22 did (11%). For the remaining patients, CPR was predictably futile.
The conversation must happen now. Encouraging doctors to start these conversations, and training them how to do it, is vital. Even more important is raising awareness among patients who may be approaching the last year of life, so they can start the conversation with loved ones.
This conversation has taken half an hour. Not long in the life of the patient, relative to the magnitude of the subject under discussion. But very long in the context of a ward round. Never mind. The time must be taken.
We come to the third patient.
I enter the bed space. The visit proceeds along routine lines while I make a general assessment. Then I reach a fork in the path. Now is the time to level with them. But I am not up to it. I have left two patients in mute distress (how could it be otherwise?). I have reformulated the words to keep them fresh and sincere and specific to them. I have struck a balance between brutal realism (I’m not one for drawing a vivid picture of CPR, but the act has to be mentioned) and sensitivity. I have asked myself, as we continued our progress along the ward, if I am I being too pessimistic. If the other doctors they saw didn’t bring up dying, perhaps I shouldn’t either? I make a decision. Not today. Another day. Let’s talk about it on Wednesday. I haven’t got the energy. Or I’ll ask the registrar to do it, she’s good.
“So are they still for resus?” asks the nurse, who needs clarity. It is she who will have to call the crash team if there is a sudden collapse.
“Yes.”
“Even if he deteriorates? He looks so … frail.”
“We’ll cross that bridge when we come to it. Sorry.”
And so we move on, hoping that the worst doesn’t happen before we find the time and the energy – a very specific form of energy – to broach the subject.
Philip Berry is a consultant in gastroenterology, hepatology and general medicine
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