Midnight Musings on Dashes of Death

There's nothing like a dash or two of death to spice up a particularly boring Monday at the hospital.

Okay, I'm kidding. It was all rather dreary and depressing, which makes it perfect for a midnight pre-sleep muse.

Our consultant ward round today mainly consisted of 2 patients, both terminally ill.

One was a lady, bless her poor soul, who'd suddenly taken a turn for the worse, becoming confused over the weekend. It was quite a shock for me, especially since I'd seen her on a ward round last Friday, when she was sitting up and looking lively in bed, complaining about not being able to swallow, and being able to follow the doctors' discussion pretty lucidly. At that time, it had already been decided that she was to be treated palliatively as she had pretty advanced colon cancer. However, because she still had a grip on things on Friday, the doctors were willing to investigate her swallowing problems.

It didn't strike me how complicated palliative care was going to be until today when her deterioration was discovered. The consultant was discussing plans of action with her son, and the only real thing he was offering was morphine injections to ease the pain. Possible infections causing the confusion: no antibiotics to treat the infection, morphine for the pain. Swollen leg with a beginning of a pressure sore, possible DVT: no anticoagulant therapy, morphine for any pain. Difficulty swallowing, even fluids: no OGD +/- balloon dilatation, no investigations or therapy, but slow feeding with whatever she can get down. Weeks to live, so try and move her somewhere else to die. Given, I'm painting a pretty bleak picture of this case (it's the midnight thing I bet) but it IS quite ugly. All the things she has are treatable, but just because she has a terminal illness she doesn't get treatment.

On one hand, I understand that she doesn't need those treatments, as even if they do work they'll just be getting her well enough to die - a drain on resources and time, and a whole lot more suffering for her eg. in the form of invasive treatments and millions of needle-pricks. Yet the main aim of a doctor seems to be to treat what can be treated as best as possible, and for me, the trainee, it goes against my instinct of "investigate and treat" not to try and make someone "better". The helplessness is quite sobering.

In the end, she will die (as will everyone else), no matter what is done for her. Palliative care aims to keep her as comfortable as possible until the time comes for her to meet her Maker. It is accepting death, and getting someone ready enough to meet it with a peaceful smile on his/her face. It needs some getting used to, definitely, and it'll be tough loving this way of learned helplessness, but in the end, it is a humane and compassionate way of treating patients who have the end in sight.

(And I'll never do geriatrics.)

The 2nd patient was a old man fobbed off ITU/ICU into the hands of the gastrointestinal team I'm attached to. Being a new patient, the team pores over his notes, picking up the salient points, getting ready a plan to treat him. Then they see the patient, and the plans get thrown out of the window. Alcoholic liver disease, previous MIs, now with massive ascites unchanged with drainage, and with a tracheal tube and nasogastric tube in.

(Never ever chronically drink tons of alcohol, unless you want to land up on your back at around 50 with a massive belly of ascites and lots of other complications besides.)

He was taken off the ITU/ICU so he could pass on in perhaps less intimidating surroundings, and the GI team seemed like the logical choice as fall guys, what with the liver disease and all.

(And I'm not going to do GI medicine either - the number of cases of terminal alcohol-related problems is enough to turn me away, and then you have the scopes that they use to investigate - rigid or flexible, from the top or bottom, etc.)

For him, the dreary palliative care pathway is just beginning, and it'll be a tough walk for him and his family, as well as the doctors looking out for him.

It's inevitable that in the future I'll be dealing with these kind of patients. It'll be tough, and hopefully I do, but don't really, get used to it, and maintain that certain uneasiness about getting someone comfortable enough to die. As for now, I'll comfort myself with the fact that they will be as comfortable as possible as they wait for their turn to go.