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A difficult farewell

April 22, 2007

One of my longest standing patients came into the hospital last month. He had oesophageal cancer, and has had several courses of chemotherapy, which have given him a very good quality of life for 3 years. When I first met him, I told him that I expected his prognosis to be between 6 months and a year, so he had been lucky. Unfortunately he was now at the stage where his cancer was progressing rapidly and there was nothing more I could do to reverse that process. He was dying.

We had become friends over the last few years , and I found that I could talk to him quite easily about what was going on, and was able in a small way to make his last few days easier. Among other things we discussed a “do not resuscitate” order (he laughed). Although I was not there when he died, I was quite close at hand. His family were with him and he died peacefully and painlessly.

This is what my work should be. I have helped someone with a terminal illness to enjoy 2 years that they would not otherise have had. I had reduced his chemotherapy schedules to minimise the impact on his lifestyle, an experiment with which I was quite uncomfortable at the time , but which was undoubtably the best thing for him. Instead of a protracted deterioration over several months, he was well up until 3 days before he died. Unfortunately things do not always go so well.

His wife wrote me a very kind letter thanking me for my help. So far I have not been able to reply, and I don’t know why. I suppose it is a form of grief reaction-denial. I certainly don’t like to believe that he has died. But I think it’s more than that. I think perhaps he made me believe that I had some power to control the uncontrollable-he gave me a false sense of my own power or ability which has now, inevitably, as it was always going to, gone. Perhaps it is that for which I am truly grieving.

And yet, when I ;ook back on the last 3 year I realise that this was a story with 2 sides. From the start we had an unusually balanced doctor-patient relationship: Whenever I was struggling, he would often offer me solutions. We were both prepared to make compromises to find the best way forward. We had what is politely described as “full and frank exchanges of views” on several occasions, but always with indefatigueable good humour. When he was dying, he made my job easier by laughing. I think perhaps that he gave me more than I gave him, and maybe I’m guilty about that.

But I know that in years to come I will remember him when I am talking to patients about their prognosis, and that his story will give hope to many of them. And that I will remember him when patients are telling me about the impact of their treatments, and I hope I will listen more. And perhaps when it is my turn to die, I will remember him and find the courage to laugh in the face of death, and make life easier for whoever is with me.

And now perhaps I can write that letter

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12 comments

  1. Great story. I don’t think my sister was quite so lucky with her consultant before she died of breast cancer.


  2. “This is what my work should be.”

    Hi Mens Sana,
    so were you the Consultant, the Specialist or GP.
    See I have no criticism here:
    Your prognosis was betwen 6 months and a year
    Therapy gave him a ‘very good’ quality of life for 3
    You developed a personal relationship.

    And nowhere do we discuss how much his treatment cost
    There is a service (and within its limits) I’m sure the best possible was done to extend his life and preserve his quality of life.

    Sadly we are not miracle workers yet
    And hence the disease and ‘inevitable’ death took hold
    I presume you can sincerely say, that cost was not an issue and if there were anything more or better you could have provided, or done (you would have).

    That is not the same as having a condition like say, problem teeth – and those who should be working to save your teeth – refuse you the treatment available (because of some false argument about cost).
    They simply refuse to provide the treatment, then they’ll argue the treatment the patient requires is not available or does NOT exist, then they’ll argue it is not available on the nhs (even if it is), then they’ll argue they are simply not obliged to provide the treatment (it is dicretionary) – and then they’ll make the case against the patient as a problem patient

    This surely is contrary to all Medical Ethics
    This surely is against the ethos of the NHS.

    But it is justified everyday by hospital managers, PCTs, Consultants, Specialists, and even GPs – whether it be the case highlighted by Elle about a drug therapy (treatment) which may save a patients sight – or adequate and timely dentistry which may save a patient’s teeth.

    1) The pharmaceutical industry would rather charge £12,000 a year to treat 1000 patients, than £6,000 a year to enable PCTs to treat 2000 patients. Yet the production costs are ‘nominal’ – and the net profit would be the same. But they have their eye on the additional profit of treating 2000 patients @ £12,000
    There’s keeping the eye on the ball – but which ball?
    2) You have dentists who do not want to offer nhs services to patients who need the most work, labour intensive (and unable to charge the nhs high fees) so they settle back in their surgeries to treat children and the general public with a free check up on the nhs, plus the additional inflated ‘private’ charges for small interventions, and a patient or two a week able and willing to pay £1000 or £2000 for treatment.

    Of course if the nhs were willing to pay £1000 or 2 for every nhs patient needing dental work – all of a sudden dentists would be falling over themselves to do work – which at the moment they tell patients who cannot pay – is not possible or not available.

    But surely if the NHS pays for my practice costs, dental nurse, (anaesthetist), and secretary as well as paying me £100,000 year a salary – I should be looking at how many patients I can treat – as long as it doesn’t interfere with my golf. And not using the nhs to trawl thru patients to discover which ones can pay and which ones cannot, instead of trawling thru patients to see which ones need treatment (regardless of ability to pay).

    See, I enjoyed the luxury of RAF hospitals, when military hospitals (including dentistry) were better equipped and staffed than nhs hospitals – and cost to the patient was never an issue – the issue was simply the cost (funding) to provide the service.

    And I presumed that to be the standard to aim for!

    But alas introducing costs, internal markets, so called market forces, R&D costs, vested interests (to create waiting lists, and to refuse nhs treatment on anything they could charge more for ‘privately’) and government targets … distorted priorities.

    Let Us not forget the priority should be Patient Needs
    I watched Andrew Lansley today extol, that authority should not be top down (from government) but be given to doctors – When was it ever taken away from doctors?

    And I’m watching Civil Action (with John Travolta)
    The US and American Capitalism & legal action costs have distorted &corrupted Medical Services to the nth degree. I don’t believe there is the same risk here except in exceptional circumstances of abuse,like Shipman?

    But really, really Mens Sana,
    there should be nothing else on a doctors or surgeon’s Mind – than what does the patient need, what is the best we’ve got … and how can we improve the services.

    Now the services at Clinic 8 Addenbrookes can be vastly improved. As for other Clinics or Departments I cannot comment – since – since I had a ‘difference’ of opinion with the Consultant at Clinic 8, I have been unable to review other services @ Addies.

    You’d thing the Health Service, and Medical Profession should welcome constructive criticism and scrutiny.
    And I should have liked to have stood as staff candidate for the Board of Trustees at this years elections, but the previous candidate stands unopposed

    To say I am disappointed with the profession and with health services in Cambridge – does not mean I think it is all bad – it just reflects my suspicions of anyone who is not prepared to face scrutiny or criticism. What have they to hide?

    What have good doctors, surgeons, consultants or specialists to fear – services & treatment can be improved (in some cases are improved every day) – and the first step necessary in this process is to have an Open Mind.

    As for your friend, let me offer his wife condolences for her lost – but death comes to us all – we can sometimes delay the inevitable – but inevitable it is

    Of course, I think we would all like to go quietly peacefully and ‘suddenly’ or unexpectedly – rather than wondering if each day will be our last.


  3. Very moving, Mens Sana. True heroes, both of you.


  4. Not a hero, I’m afraid. It is after all my job. But I think we were both lucky to have connected on more than a professional level, which as JJ comments isn’t something that happens all the time


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  6. Lets hope so Q9. Our immune system is more powerful than any drug, if we only knew how to harness it


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  8. Now thats what blogging should be about, a real insight . What I like about this is that you avoid syrup and apply some thought to what has happened.I also like your acceptance of death as a a fact of life. Death and pain are not avoidable … I read in the DT today about an 85 year olds wait for MR and physio for her back problems.Well of course.It is OBVIOUS that expanding capabilities and needs cannot be provided free without alterting the way maths works. If we started from that reality we wouild have more chnace of arranging a fair and efficient system

    “From the start we had an unusually balanced doctor-patient relationship: ”

    I have had an appalling experience with the medical proffession for the most part and loathe the weakness of your position… On the other hand I recall one particularly detestable and arrogant Doctor determined to ignore my opinion who turned out to be right and helped me a lot….

    What does one make of that . Ignore the exception and stick to the rule has been my view thus far…..YOu want the Doctor to listen to what you know but you also want them to offer guidance and take responsibility.

    Easy !! What are you moaning about , get back tot work MenS


  9. Thanks NM. I always think its the Doctors job to tell the patient what they ought to do, but not to get offended if they ignore your advice. Someone once asked me for my opinion about a herbal remedy, and when I (I thought diplomatically) said I didn’t have an opinion, they really gave me a piece of their mind. Since then I have always offered my view. Sometimes I have even been right


  10. Presumably it is easier to have this sort of relationship with a patient (ie to treat the patient as another intelligent human being) when the patient treats you as a human being, rather than a cross between an authority figure and a service provider and in both cases an impersonal one.

    It’s very easy when you are seriously ill to lose your normal standards of courtesy and consideration when dealing with others, but IMHO it’s very important to try not to do so. And important to learn to laugh in the face of death.

    Many working people these days have learned in their own job that “the customer is always king” and I think this has had an unfortunate side-effect that when they are the customer, they think that rude and unreasonable is OK. When they are a “customer” in relation to medical problems, the effect is increased by their fear and sense of helplessness.


  11. This is very moving, we don’t often hear of doctors forming such close bonds, we imagine the relationship to be purely clinical.


  12. Q9 sorry your original comment got caught up in my spam filter-maybe too long? Of course you are right that cost shouldn’t come into the equation, but it is a fact of life that it does. You are also right that the internal market distorts some health priorities, and you have obviously not been well served by either the medical or dental professions, for which I am sorry.

    Potentilla and Ellee thanks for your comments. I think the setting of a consultation dehumanises both parties to an extent and makes us act unnaturally. This may be advantageous: I don’t think my career would be very long if I was to fully invest all my emotional capital in every patient, and indeed if you do, it tends to cloud decision making. But I agree things are easier if everyone is trying to get on and remain polite



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