In one of my previous practices, when I was a trainee with little experience, my supervisor called me into their room to tell me about a home visit that had been allocated to me. The patient had been discharged from hospital that day. She had cancer that had metastasised to the lungs and had told the doctors at the local hospital that she wanted to die at home. As a trainee it was quite unusual on short placements at GP surgeries to develop relationships with patients who were nearing the end of their lives and requiring palliative care. It was felt that it would be instructive for me to have that experience. My supervisor thought that I was ready; I wasn’t so sure.
As I walked into the crowded living room, I declined a cup of tea from one of the many relatives who had come over to help her feel at home. I sat down next to the patient and we chatted. Really there was nothing much for me to do. She was sat on the sofa, alert, not in any pain but a bit short of breath. If I had been a bit more experienced I would have noticed and paid more attention to her peripheral cyanosis.
As a junior doctor working in a hospital I had seen many patients die. This didn’t tend to include those who had ‘Do Not Attempt Resuscitation’ forms in their notes. When they slipped away there was no call to the ward. In retrospect, I probably hadn’t seen many ‘natural’ deaths, but had been involved with almost violent struggles to prevent patients, who had already died, from dying. Patients in hospital died with cannulae in place, masks clasped over their faces, or tubes in their tracheas. They had almost as much adrenaline coursing through their veins, if we could create an effective circulation, as we did working on the resus team, running the length of the hospital site when our bleeps went off. The inevitability of failure always hung in the ward as we arrived.
And now it was just the patient, and what felt like her entire family, in front of me in her own home. We talked through the plan for the next period of time, the length of which neither of us seemed to want to discuss. It involved discussing the case with the district nurse, getting a hospital bed, and arranging anticipatory medications, once I had learnt what they were and how to prescribe them. It seemed to go well, though I knew I would have had quite a lot to sort out the next morning.
The following day, before I could make any phone calls I had a note from my supervisor to check my messages. It transpired that after I had visited, my first palliative patient had fallen unconscious that evening on the very sofa where we had chatted. The family didn’t know what to do. I hadn’t spoken to them about what to expect, probably because I didn’t know what to expect myself. The previous day she had been much closer to death than I had realised.
The most certain thing in life is that we die and yet often the most uncertain aspects of death, and what patients and their relatives want to know, are how and when. I’ve learnt now to hedge on the side of pessimistic and to prepare relatives for what the dying patient often knows in their heart of hearts. My communication with district nurses and accessing of support from specialist hospice nurses has improved in the intervening years. But I expect it is only a matter of time before I am caught out again.