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.