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‘Make the care of the patient your first concern’, this is the first rule and as rules go it seems pretty black and white. The more I practise medicine though, the more I find grey everywhere, even when it comes to rule number one.
It’s 11pm and I am on a ward with a patient who is dying of chronic illness. She is 60 years old with a husband, son, sister and mother. That her mother looks fitter and younger than she does is immediately apparent and it adds an extra layer of poignancy to the situation.
The patient had severe heart failure and enough other chronic conditions for me to know this was probably a terminal event. She was too ill to communicate with me, so I sat with her family and asked if they had ever discussed with her what she might want at a time like this.
The answer was no.
Chronic illness is tricky like that. As a doctor I knew she was dying, but for patients and relatives there is no abrupt trumpet call. Chronic heart failure doesn’t come with the same aplomb that cancer might and often, the dying just creeps up on people. They are surprised.
She comes to intensive care for non-invasive ventilation and I tell her family that that is the only shot we have. If this option fails, we will not put her on a ventilator. If her heart stops, we will not try and restart it. Her mother puts her hand on mine, squeezes and says: ‘I know you will bring me good news.’
I know I will never bring her good news.
I think about why I have taken this patient in to intensive care, this shot in the dark. I was more sure than not that she would die but I was absolutely sure that her family weren’t ready. I was sure they needed to see this stage fail. I am treating this family. I am treating them as a unit, the patient and the people that she loves. My actions are all defined by shades of grey and I feel oddly insecure. I worry that I have become lost.
The family sit with her and I gradually spoon-feed them reality.
Two hours pass and I have evidence that non-invasive ventilation has failed. We sit down for the third time that night and I say this is it. I explain that the right thing for me to do now is to make her comfortable as she died.
Tears flow down her mother’s face ‘she promised she wouldn’t die before me’ and she takes my hand again and asks if half an hour more might help.
But in that moment, things are black and white again and I am standing on a line that is as clear as day. I keep her hand in mine and tell her no, and I am kind but resolute; found.
‘Make the care of the patient your first concern.’
By the Secret Doctor
Read the blog and follow @TheSecretDr on Twitter
Good job. Be strong for your Pt. ❤️