Chapter 2.4: Last throw of the dice

It’s been a while! The outpouring of celebrities clamouring for my return has weighed too heavy on my mind, so I’m back with more reflections.

In all seriousness, I’ve had a bit of a social media cleanse (there may be a post coming up on that) and took a little step back from my peripheral projects, hence the Houdini impression. It’s good to be back though.

This particular patient encounter happened a while ago, but is really something that surely occurs on a daily basis in clinical practice. We approach medicine with an optimistic, curative intent and thankfully, we save lives everyday (I say we, for the time being I mean them!) However, it is a fact of life that some people cannot be saved, even with the full might of modern science.

The highest of stakes

This is a longer story but one I hope you’ll find of interest.

I haven’t ever been confronted with my own mortality, but I imagine it would put everything into perspective very quickly. As humans, we are evolutionarily programmed to pursue our own survival, until we can pass on our DNA via offspring. From a more modern point of view, our lives are a constant pursuit of the next milestone; school, further education, jobs, families, wealth, success. The thought of that journey being abruptly truncated, goals never to be attained, is understandably distressing.

I had the pleasure of speaking to a respiratory (lung) patient quite a few times. He had good signs for examination practice, a good story for history taking and even required some additional oxygen so I could sign off some skills.

I visited him during a moment of (increasingly dwindling) motivation to see how he was doing. You see, this patient had longstanding emphysema- essentially, he was trying to get his oxygen from two floppy lungs that had huge empty spaces where lung tissue used to be. After a nasty infection, his ability to breathe, even with additional oxygen, was severely compromised.

I visited him just after he had been told by his doctors that this was probably it for him: he wouldn’t get better and would probably spend his remaining few months on increasingly strong oxygen support until inevitable respiratory failure. I had previously told him about my time in ICU and he quite strongly told me “I don’t ever want to be hooked up to one of those machines [ventilators], I’d rather pack it in”. At the time, he hadn’t been told the news yet.

This day was different. He was quieter, avoided eye contact and spoke with an almost apologetic tone. He began to ask me some questions that prompted me to write this piece. It turns out he had been researching his disease quite extensively for a few months and had discovered a number of potential routes for treatment.

He began to list of a number of experimental, sometimes anecdotal, stories and studies for end-stage emphysema. Everything from super doses of vitamin D to experimental immunotherapy, to radical diets and re-purposed drugs. His energy picked up a bit as he described them. Unfortunately, I knew what was coming next. The words no medical student wants to hear:

“So tell me your honest opinion, do you think they’ll work?”

We’ve had plenty of skills training (and actual clinical practice) to negotiate this scenario. The “gold-standard” approach is to:

1. Ensure you clarify that you are not a qualified doctor
2. Ask the patient more about their ideas, concerns and expectations
3. Encourage them to talk to their doctor (or, depending on the scenario, speak to the doctor yourself)

This works quite well in a simulated setting, but in actual practice when the topic is life-or-death, this approach can really fall a bit flat.

Back in my first clinical year, I had a similar scenario where I was left alone with a patient whilst her doctor went to get the tools for a punch biopsy of her breast, to tell if her lump was breast cancer or not. The patient, of course, knew that by taking a biopsy there was a possibility, and proceeded to ask me “in your honest opinion, do you think it’s cancer?”

In both of these scenarios, my approach was slightly different. With the breast lump patient, I was a nervous baby student who had never been left alone with a tearful patient, pleading me to reassure them that they didn’t have cancer. My approach was basically that above: I said I couldn’t say as I wasn’t qualified, tried to reassure her and reminded myself to check later whether there were any reports of time slowing for a bit at 3pm in Huntingdon.

However, with this lung patient my approach was slightly different. I made sure to give him the caveat (it’s a sensible approach to cover yourself, as well as remind the patient that even though I have a stethoscope I don’t have the title yet) but I wanted to avoid the feeling that I got with the breast patient. That I was useless, I couldn’t provide any support or insight and probably sounded like I was trying to weasel out of giving her a cancer diagnosis.

I spoke with him about these studies and stories, what his opinion was on them, whether he had told any of his doctors or healthcare team (he hadn’t). I formed a plan with him: who he would speak to, what he would say, what they were likely to say to him. I genuinely think I made him feel 1% better because, even though I made it clear there was no guarantee, there was still hope. Not false hope, but hope.

I’ve been meaning to follow up on him for a while but life has taken over (reading that back, that seems like a poor choice of words). I guess my main reflection from this is that we, correctly, learn how to negotiate these difficult scenarios, but with time I think it’s possible to use some common sense and tweak the usual spiel to actually help. I also think as medical students, we should get comfortable talking to patients about death and distressing diagnoses. It teaches you a phenomenal amount, because a patient who is facing death will not pull any punches. They will be honest about you, about life and about how you can support future patients who are in their shoes.

As for me, I’m very much at a place where I need to begin assessing my options, start to direct my energy into more long-term goals and ensure I don’t take time for granted.

Thank you for making it this far, let me know your thoughts on my approaches for these patients and hope you’re staying safe and well.

Also f*ck the European Super League.

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