‘I don’t know.’
This was something I said quite a lot on Wednesday, because I had a year 12 student shadowing me for work experience. Having somebody who is entirely new to the ideas of medicine following you around for a day is an eye opener I would recommend.
Questions… so many questions.
‘So, the letter says he wanted to die at home?’
‘Why is he in resus?’
‘Is he just going to die now in a minute?’
‘Does he know?’ and I say: ‘That, I really don’t know.’
‘Didn’t his wife know that he wanted to die at home?’ And I say yes, but that watching the person you love dying can be a frightening thing when you’re by yourself, maybe she wasn’t sure what dying was supposed to look like, maybe she had difficulty coping. I tell her that the community palliative care team hadn’t gotten out to see them yet.
‘But why not? The letter said they would.’ And I say: ‘That, I really don’t know’.
‘If he’s going to die anyway, why was the other doctor trying to get a cannula in? Is that for drugs?’ And to that I think, where can I start?
‘So, that lady isn’t coming to intensive care either?’
‘Because you can’t make her better?’
‘Where will she go?’
‘Is she dying too?’ and to that I say we’re all dying to different degrees, she’s not dying today, this is more of a short to medium term dying situation. That man from this morning, he was dying today.
‘And what is she dying from?’ and I say it isn’t really one thing, there are lots of things that are wrong and today they got a bit more wrong, but there is still isn’t anything I can do in intensive care to make that better.
‘And you’re giving that man the drug to break down a blood clot?’ And I reply yes, because the clot is putting his heart under strain and that’s why he is struggling with such a high heart rate and low blood pressure. I tell her that his heart can’t maintain his cardiac output.
‘And he might bleed?’ and I reply that yes, it is a risk with thrombolysis for massive PE and that this patient is very unstable and needs treatment very quickly.
‘Does he know?’ and I reply that yes, I have told him there is a risk of bleeding.
‘And he said ok?’ and I reply that he asked what we would recommend and I told him that the intensive care and medical teams involved in his care believed that the potential benefits of thrombolysis outweigh the risk of bleeding.
‘So, he won’t have a bleed?’ and I reply that no, I can’t really know that, but that he didn’t have any other risk factors to suggest he would be in the group of people who are very likely to bleed.
‘But you don’t know that?’ and I reply that no, I don’t.
‘And does he know he might die?’, and I reply that I didn’t mention that word, specifically.
‘But you said the treatment for this sort of clot is life saving?’
And I reply that yes, I did, but I don’t think he will die, that’s why I’m giving him this treatment.
‘But you don’t know?’
And I reply. No.
Thank you for the questions.
By the Secret Doctor
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I literally would have told that work experience student to go do some reading.
Thank goodness most of my work shadowing students ask more interesting and sensible questions. [I usually say 'I'm not sure' rather than I don't know - it comes to the same thing really, but doesn't sound quite as stark.]
[full disclosure: I'm not a medical student] as a (hmmm) non healthcare professional, regular person-sometimes-a-patient who delves into end of life nuances and conundrums (bestendings.com) this is helpful, insightful, illuminating and serves to put into perspective in to the grey and greyer, the knowns and unknowns of the human condition. Thanks.
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Thank you for this article. I'm glad the work experience student got the opportunity to talk to you. And I'm impressed that you took something from the experience too - we should all aim to learn from working with each other.
I often ask my medical students which phrase do I repeat most frequently- to the patients and to them- and it is exactly "I don't know ". I spend entire day's not knowing!
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