One of the first things I was ever taught as a student nurse was that people will forget what you said, they will forget what you did, but they will never forget how you made them feel. It is a sentiment that I have carried with me in the decade spent caring for patients since then.
It was a busy Wednesday evening when I looked after an elderly man (let’s call him Jim) who had been brought to the emergency department by his wife (we’ll call her Anne). Jim had mild dementia and his wife had noticed that he was losing weight, had lost his appetite and was becoming more lethargic. “He’s normally so healthy” Anne told me, “he hates coming to hospital, but I was worried he might have pneumonia”. After taking a thorough history, examining Jim, checking some blood tests, getting a chest x-ray and reviewing notes from his GP, the cause of his symptoms became clear. Anne had brought with her some paperwork from a recent colonoscopy, along with a series of scans and blood tests done by the GP. Jim had bowel cancer which had spread throughout his body, however he and his family didn’t seem to know.
How do I, as someone who only met Jim an hour ago, deliver the heart-breaking news that he has cancer which has spread throughout his body and is slowly killing him? How do I break it to this man’s wife of 70 years that her husband will only continue to deteriorate further into a shell of the man she married? How do I tell Jim’s two children, who have now also arrived, that their Dad is dying?
No matter how many lectures or role plays you sit through on breaking bad news, giving patients a heartbreaking test result or diagnosis just isn’t a skill that can be taught, it has to be shaped and crafted through first-hand experience.
I pulled the blue curtains around Jim’s bed and sat down with his family, who all smiled at me eagerly as though I would be able to give them the answer they had brought Jim here for, and crack on with fixing him.
“Did your doctor ever give you the results of your recent colonoscopy?”
I began tentatively, however I couldn’t delay the news much longer.
“The growth that they removed at the time was cancer, and the other tests that your GP sent you for afterwards showed that the cancer has spread to your lungs and liver.”
“I’m so sorry Jim, but I think you are feeling unwell because the cancer is continuing to spread.”
Usually a diagnosis of this magnitude is delivered by a specialist at the time of its discovery, and I wondered whether there had been a decision made, either by a family member or Jim himself, to not find out the test results. But when he came to ED with clear symptoms of his cancer, it was in the patient’s best interest to know that there was a cause for the way he was feeling. Due to his age and other health issues he did not want to pursue any active treatment. I spent quite a long time talking to Jim and his family, explaining what palliative care was, and the services that community palliative care nurses could provide to enable him to stay at home and comfortable.
For those moments, the blue curtains that separated the patient’s bed from the rest of the department felt like they had separated us into our own timezone, where I didn’t notice the beeping of IV pumps or cardiac monitors, the PA system announcing the arrival of another patient with chest pain or the constant hum of activity in the background.
I finished getting Jim organised to be discharged home, with plans for him to be seen by the community palliative nurses. I encouraged his family to keep taking Jim out to his favourite coffee shop, let him eat as many Iced Vovo's as he liked and spend as much time together as they were able. The most important thing was not the number of days or months Jim had left, but the time he was able to spend with his wife and family and doing the things he loved.
As a doctor, it can be very hard to take a step back from the history-examination-investigation-diagnosis-treatment mentality to refocus on simply allowing a person to have a dignified end of life with management of symptoms and allowing death to happen without furiously holding it at bay. Having previously worked in an area of nursing where I was heavily involved in end-of-life care for patients, I felt slightly more at ease sending Jim home without a definitive treatment for his condition and instead allowing him to be kept comfortable.
Jim was ready to head home after a visit to hospital which I’m sure will be replayed in the minds of his wife and children for a long time to come. I walked over to him with his discharge paperwork and wished him and his family all the best. Anne took my hand in both of hers, with tears in her eyes and thanked me so genuinely for being patient, understanding and helpful; as if I’d been able to fix her husband after all. Jim and his children were also so kind and thankful, echoing Anne’s thanks and reminding me that it’s not what anyone says or does that we remember, it’s how they make us feel.
I won’t remember the exact words used by Jim or his family, but I will always recall that they made me feel like I had done my job well and been the type of doctor I will always aspire to be - kind, caring and my patient’s number one advocate.
I had an hour left of my ten hour shift when a patient had a sudden and unexpected cardiac arrest in the emergency department. I took over CPR on the third cycle (doctors and nurses rotate giving CPR every 2 minutes to minimise fatigue and maintain strong compressions). By the time my hands were on the man’s chest, there was already a tube down his throat allowing another doctor to provide artificial breaths, multiple lines into his veins delivering adrenaline to try and encourage his heart to restart, and he had been shocked with a defibrillator twice. It was a very odd sensation to finally be delivering cardiac compressions to a real human after so many simulations on dummies. In other resuscitations I’ve been involved in, it was my job to get another drip in, or to get the latest blood test results or send more blood off. My own pulse was skyrocketing as I climbed on top of the hospital bed and started pressing down on the unconscious man’s chest. Several of the man’s ribs were already broken, and his sternum was freely depressible deep into his chest. Try pressing inwards on your own chest - it doesn’t feel like one of those CPR dummies… but I can tell you that once the ribs are broken by the initial compressions, the dummy is a fairly realistic simulation.
I did several cycles of CPR throughout the resuscitation effort on this man. While my hands worked to try and squeeze his heart to deliver vital blood to his brain, a flicker on the defibrillation monitor and a hand over his carotid artery showed that he had regained a pulse. For a split second it seemed things were looking up and my own pulse again was racing. Unfortunately a swift ultrasound of the heart and another glance at the monitor painted a more dire picture. After close to an hour of CPR, defibrillation, drug therapies and ventilating by a team of doctors and nurses, further efforts were deemed futile. The entire team stepped back in silence as the head doctor solemnly announced “time of death, 10.48pm. May he rest in peace”.
I have witnessed the final moments in the lives of many patients. Whilst working as a nurse, I held the hand of an elderly lady as she gasped for her last breath. I have examined recently deceased patients to certify their life extinct. I have made the awful call to family members to give them the heart-breaking news that their loved one won’t live to see another sunrise. But this death was different.
This was first patient whose chest my hands had worked on to try and bring back life. This was the first patient who I witnessed complete the transition from life to death whilst working as a doctor.
It says a lot about us as doctors and nurses that after a brief pause to debrief and regroup, we all dove right back in to the rest of the department, where every other patient is unaware of what we have just witnessed. We all become a bit desensitised to just how profound it is to witness another person’s final breath, and this is necessary to some degree or we just wouldn't be able to function. It is easy to forget that we really are in a privileged position to be on the frontline to be involved in other people’s lives beginning, ending and all the most difficult moments in between.