I took a seat in the armchair and politely nibbled on my biscuit while Mrs Briggs began to explain why she had asked me to visit. I was making my best effort to listen intently, but I couldn’t help but be distracted by Sinbad. The dog had started sniffing intently around his owner’s lower legs. This in itself was only slightly disturbing, but he then started enthusiastically licking the hard crust of skin on the soles of her feet. He systematically licked the entirety of each foot in turn, even endeavouring to squeeze his tongue between each of her swollen toes. After completing this, Sinbad focused his attention on a particularly hard callus on her left heel. After softening it up with a particularly vigorous lick, he began gnawing at it as if it was a tasty bone. I couldn’t quite believe what I was seeing and initially wondered if Mrs Briggs was even aware of what was happening, but as Sinbad struggled to get a good vantage point on which to clamp his teeth, she purposely manoeuvred her foot to a more accommodating angle.
Mrs Briggs was talking away, but I had very little recollection of her words. All I could focus on was the relish with which her elderly Jack Russell was feasting on her dead skin. Surely this couldn’t be healthy for either dog or human? Yet, I got the impression from their mutual sense of ease that it was in fact something that they had both been enjoying for some years. After around 10 minutes, Sinbad appeared to have had his fill of foot, but, clearly on the lookout for some dessert, he jumped up on the sofa and began sniffing around the saucer of shortbread biscuits that was perched on an adjacent side table. With the same sort of concentrated deliberation he had shown his owner’s feet, he licked each shortbread finger on the plate from top to bottom and then chose one that he liked the look of and began chomping away messily.
Finally taking some notice of her dog’s inappropriate dining habits, Mrs Briggs shooed Sinbad away from the saucer of biscuits and then, without the merest hint of shame, held the saucer out in my direction and offered me another. It was at this point that the harsh reality hit home. I had no way of knowing if Sinbad had already given the shortbread fingers a good going over before my arrival. Even as a glass-half-full kind of guy, I still couldn’t get away from the fact that it was quite likely I had just eaten a biscuit laced with dog saliva and foot scale. My gag reflex began triggering uncontrollably and God knows how, but I kept myself together and managed to leave the premises before vomiting.
John
John wasn’t the easiest of patients. He rarely took my advice on anything but still enjoyed coming to see me now and again to get a few things off his chest. He drank too much and he worked too hard and his diet was pretty awful. He didn’t need me to point out that his health was suffering as a result, but like so many of us he seemed trapped in his bad habits. John reluctantly took pills for his high blood pressure, gout and raised cholesterol. He always had the aim of changing his lifestyle so he wouldn’t need the medicine any more, but despite gym membership fees leaving his bank account every month, he was much more likely to grab a bottle of wine and a takeaway curry after work than eat a salad and run 10 kilometres on a treadmill.
John was in his early 50s and was still bitter about the break-up of his marriage almost eight years earlier. He blamed his ex-wife and ‘that bloody bastard’ she ran off with, but he did admit that he had spent far too much time working on his career and too little effort working on his relationship. He had also confided in me that his marriage had never really recovered from the stillbirth of their son 20 years earlier. He always felt that he should have somehow been able to have prevented his son’s death and he explained that feelings of blame ate away at him. He had always shooed away my suggestion of counselling, instead choosing to throw himself further into work and drink.
I had seen John miserable and angry many times, but today he seemed genuinely depressed. This was the first time he was questioning the point of going on; he wanted me to keep this off his record, but he had actually begun to seriously think about suicide. I was really worried about him, and wanted him to get some help, but as usual John dismissed the idea. I thought at least he would let me sign him off work for a few weeks, but no – despite all his anger and bitterness towards his career and the detriment it had caused to his life, he couldn’t quite imagine living without it. He had a fierce loyalty to his job and over the years it had taken pre-cedence over every other component of his life. You would think that, given its hold over him, John would at least be passionate and enthusiastic about his career, but when I asked him about it, he told me that as each year passed he found it increasingly hard to take any sort of joy or satisfaction from a day at work.
Normally it’s me needing to hurry along a consultation due to poor time keeping, but on this occasion it was John who brought our consultation to a close. He needed to get back to work. I watched him from my window frantically rushing back to his car.
As he accelerated out of our car park, I could just picture him speeding recklessly the few miles across town, running past his secretary, turning on his computer and grabbing his stethoscope.
I hoped his first patient of the afternoon appreciated him and wasn’t too disgruntled about him starting his surgery 10 minutes late.
How doctors die
Doctors are human too, and much like many of our patients, we aren’t always great at looking after our physical and mental health. We live our lives in much the same way as anyone else, and although we should really have above-average skills when it comes to self-diagnosis, we will still succumb to the inevitable eventually and shuffle off this mortal coil. Interestingly though, although doctors live their lives much like everyone else, we often choose to end them differently.
We live in a time where drugs and technology allow doctors to cheat nature and keep patients alive for longer and longer. This is a fantastic achievement of modern science and every day I speak to happy, healthy people who would be dead without our medical input. This advancement does, however, have a cost. As I write this, Nelson Mandela is still alive in an intensive care unit in South Africa. The television cameras have been kept away, but any medic can imagine what sort of life someone in his situation would be living. He is likely to be asleep much of the time with most of his waking hours spent devoted to taking medications either orally or directly into his veins. The needles and blood tests will be constant, with the desperate attempts by the medics to keep his vital organs functioning. Food would be at best puréed and at worst fed through a tube. Toileting would be via a catheter and a nappy. It seems so sad that such a great man could be reduced to this.
When we doctors talk among ourselves we often promise that we won’t allow our own lives to be kept artificially prolonged in such a way. When machines and medication can keep your heart beating while nearly every other bodily faculty is failing, surely it is time for doctors to stop dragging out any last semblance of existence and let nature take its course?
As medics, our constant exposure to death and dying must affect us, and perhaps force us to consider our own mortality more intently. Personally, I still fear death, but I don’t dread it anywhere near as much as I fear being kept artificially alive in a state that offers constant pain and suffering. In his essay ‘How Doctors Choose to Die’, Ken Murray talks about his doctor friend who was found to have pancreatic cancer. Understanding the real consequences of this, his friend declined all the surgery, chemotherapy and radiotherapy that was offered, and instead chose to spend his last months dying peacefully at home with his family around him. As a doctor he had seen enough during his career to be able to make an informed choice about how he wanted his own life to end. If he hadn’t been a doctor, he may well have lived a little longer, but equally suffered a whole lot more.
But if doctors routinely choose to reject life-prolonging treatments for themselves, why do they often push so hard to keep their patients artificially alive?
There was a bad joke that went around medical school: why do coffins have the lid nailed on?
Answer: to keep the oncologists out.
/> As doctors, it can feel like stopping treatment is an admission of failure. We do often maintain treatment for too long, and definitely need to get better at stepping back and saying enough is enough. However, although we know that letting go is in the best interests of our patient, sometimes we fear that by withholding treatment we will be criticised and accused of callous laziness.
The Liverpool Care Pathway is a system that was set up to allow patients with terminal illness to die peacefully and with dignity. However, this protocol for allowing a natural death was picked up by many parts of the media as being cruel and barbaric. Grieving relatives accused doctors of allowing their nearest and dearest to die prematurely. Scared relatives requested that their dying relatives weren’t put on this so-called ‘death’ pathway, and as a result many people will have died after enduring more suffering than they needed to.
Despite all the uproar about the Liverpool Care Pathway, I always find it odd that its strongest critics never asked whether doctors would ever allow themselves or their loved ones to be put on it. As doctors, why aren’t we asked more often what treatments we would and wouldn’t give to ourselves or our own families? When I chose a boiler for my house, I asked the plumber which type he had at home. When I’m choosing dessert in a restaurant, I ask the waitress which one she likes best. There is nothing like a bit of inside knowledge when making a tough decision – and they don’t get much bigger than decisions about pudding!
Doctors make mistakes and get things wrong all the time, but we’re not, as large segments of society seem to feel, part of some sort of big evil conspiracy. For example, wasn’t it telling that throughout the whole MMR furore, I never met a single doctor who didn’t give the MMR vaccine to their own child? In the same vein, I don’t know any doctors or nurses who wouldn’t allow themselves to die on the Liverpool Care Pathway.
Having said all this, of course this is only my opinion. Who am I as a doctor to decide what should and shouldn’t be considered good quality of life and when care should or shouldn’t be held back? We doctors are accused often enough of playing God, and so in an ideal world, patients themselves would make informed choices about how they die and be in complete charge of every decision along the way. The problem is that, in reality, once we get to this late stage in life, many of us will be too ill and confused to make any coherent decisions. Relatives will be forced to make really difficult decisions; often love for a family member will mean wanting them to be around for as long as possible. I wonder if this is what is happening at the moment with Nelson Mandela? If he is still alive at the time of reading, that is. He is loved by a whole nation, and they understandably don’t want to let him go.
These difficult end-of-life decisions are never easy, but as someone who has to deal with them often my only advice is to talk to your families now and tell them how you would like to die. It is a taboo subject, but it will happen to all of us eventually. I would urge you to write a living will, also known as an ‘advance directive’ or ‘advance decision’. Don’t leave it to doctors or tearful relatives – let everyone know now what you would like to happen were you to become so ill that you could no longer make decisions for yourself.
Rita
Miss Blumenthal, the elderly Holocaust survivor, died peacefully in the night. By the next afternoon, her room in the nursing home had been filled by a new patient, Rita.
While Miss Blumenthal had been a serene and model resident, Rita was causing a bit more of a stir. I could see the exasperation on Nurse Carmela’s face as she answered the front door to me.
‘Oh, Dr Daniels, this lady is very tricky,’ Carmela warned me as I followed her through to her room.
‘Oh, come on, Carmela, she’s 92 years old. How much trouble can she be?’
Rita was sitting in an armchair at the window with a cigarette held loosely between two yellow nicotine-stained fingers. There were small brown cigarette burns all over her nightie, and as we walked in she nonchalantly stubbed out her cigarette on the windowsill, completely ignoring the pristine ashtray that was just a few inches away. Rita had a tiny frame and you could make out almost her entire skeleton under her taut skin. Her hair was completely white and its straggly appearance suggested that she hadn’t conformed to the blue rinse perm that most of her com-patriots in the nursing home proudly sported.
‘We’ve been telling her she can’t smoke in her room but she won’t listen to us,’ Carmela whispered to me.
Rita turned to look at us with some disdain. ‘’Ere, who the fuck is he?’ she asked, looking me up and down with a steely gaze.
‘I’m your new doctor, Rita. It’s very nice to meet you,’ I smiled nervously, holding out my hand.
‘He can’t be a doctor,’ Rita replied, completely ignoring my outstretched hand.
‘He looks too young to be a doctor, no Rita?’ Carmela chirped.
When I first qualified, my patients would often comment that I looked far too young to be a doctor. It annoyed me back then, but at this point I was well into my 30s and ready to take any remarks on my youthful appearance as a compliment.
‘What! Nah, he don’t look too young to be a doctor, just too bleeding stupid! Look at that face. Grinning like a fucking chimpanzee. Which brainless bugger gave him a medical degree? No wonder the whole bleeding country’s gone down the swanny.’
Slightly taken aback, I tried again with my charm offensive. ‘So, Rita, how are you settling into your new home?’
‘What ’ere? This fucking shit ’ole? This ain’t my bloody ’ome I can tell ya. Packed me off ’ere to die they did, but ’ere I’ll tell you one thing …’ Rita leaned forward and looked around as if she was about to whisper to me a great secret that no one else should hear. ‘I’LL OUTLIVE THE FUCKING LOT OF YA!’ she bellowed right into my ear and then let out an enormous cackle that sent her ill-fitting dentures rattling around in her mouth.
Once she’d stopped cackling, Rita decided that my audience with her had come to an end and she shooed me unceremoniously out of her room.
‘Go on, bugger off, you. I’ll die when I’m good and fucking ready without no meddling doctors and their dirty snake charms.’
With that, I took Rita’s less than tactful social cue to leave and wondered exactly what I could write in her medical notes that could politely summarise our consultation. I was rather looking forward to being Rita’s GP for some time to come, but unfortunately the nursing home manager felt she was a fire hazard and managed to move her on to a different nursing home looked after by another GP surgery. A great shame.
Neighbours
It was 8.30 on a Friday evening, and the blessed end to a long day and a tiring week. Amazingly, I found both of my children fast asleep when I got home, and the house relatively tidy. There was a can of beer in the fridge, a surprisingly good film starting on the TV, and, most importantly, we were due a delivery from my favourite Indian restaurant. With my money at the ready, I was sitting on the sofa impatiently waiting for the doorbell to ring. I could just picture being handed over the large brown paper bag weighed down by tarka dal, chicken korma, pilau rice, naan bread, and a bag of poppadoms that had been thrown in free of charge. All of which were guaranteed to elevate my Friday evening mood even further. When the doorbell rang, I sprang to the door like Usain Bolt out of the blocks in a 100-metre final.
To my overwhelming disappointment, it was not the curry delivery man ringing our bell; it was Tom who lived across the road. Tom was in his late 60s and lived alone. He seemed to spend an unfathomable amount of time pruning his front hedge and complaining about the council’s management of residential parking permits. He was friendly enough, but although I like the general notion of being neighbourly, my natural instinct was to attempt to avoid him at all costs.
‘Hello Ben, I’ve been having a few problems that I thought might interest you what with you being a doctor. You did always say to come over any time if I needed anything.’
Keen to avoid just such a scenario, I have never admitte
d to being a doctor to any of our neighbours, but I suspected Tom had spotted the doctor’s parking permit in my car window, giving the game away. When I had said that Tom could pop over at any time, I meant to borrow the lawn mower or a cup of sugar, not to use my house as an all-hours walk-in medical centre.
‘It’s my bowels, see, Ben. Something dreadful they are. Shocking it is. It’s just coming away from me like an erupting volcano. All yellow and the smell really is just something else.’
‘Oh,’ was all I could muster as a reply. Having happily lapsed into a post-work haze of relaxation, I just didn’t feel capable of switching my brain back into empathic doctor mode. I should really have interrupted Tom straight away and explained the importance of firm boundaries between my work and my home and between neighbours and patients. I didn’t. Instead, I stood on the doorstep in frustrated silence inwardly willing Tom to go back home. Tom was blissfully unaware of my ebbing mood and terrible lack of empathy. If he had come to see me just an hour earlier while I was still at work, I would have listened intently and offered support, reassurance and maybe even a diagnosis. But in my head I was now off duty and I just couldn’t manage any level of compassion at all.
Some of you might imagine that as a doctor I am always on duty, continually seeking out the opportunity to fight disease. The truth is, I’m not. When I’m at work I’m a doctor and mostly quite a good one. When I’m not at work, I’m a dad and a husband and someone who likes watching football on a Saturday afternoon and eating a curry on a Friday night! The only exception to this rule is a true medical emergency. Then I will step in and help if I can. I have performed chest compressions on a beach and helped at the side of the road after a car accident. Any doctor would do the same. Tom didn’t have a medical emergency. He had a bad case of the squits and my ‘passion’ and ‘love’ for my job definitely didn’t extend to spending my Friday evening off listening to the extensive details of his bowel movements.
Further Confessions of a GP (The Confessions Series) Page 17
