Tuesday, May 15, 2007

Visiting Cleopatra?

Sorry folks, another wholly unintended hiatus I'm not at liberty to discuss... I hope to back a little more regularly hereafter. Hob nobs on offer to the first to deduce the somewhat gnomic title...

And so without further ado, on with the motley.

Any GP will tell you, a request for a home visit to a patient in their eighties or beyond, where the notes are a slim folder, or latterly a near blank computer printout, with no clinical entry in over a decade, almost invariably spells bad news. Indeed generally the worst possible news.

At the other end of this domiciliary consultation there is almost always a large tumour of the breast, bowel, ovary or similar “occult” malignancy. Or rather, a patient afflicted with one of the above. A patient who has been enduring the onset of whichever it might be, silently, and for some time.

Often, though not invariably they have been living alone and untroubled by the world at large, with neighbours or other acquaintances seeing to their shopping. Being of a “self sufficient” generation they have tended to see to the cutting of their own hair, the mending of their clothes, and have their bills paid either by the same neighbours at the post office, or the bank by direct debit. Then, one day somebody turns up out of the blue, spots and odd contour in the clothing and decides it’s time to “get the doctor in”.

Of course it’s long past that time already, though there will still be things that can be done, and in the succeeding weeks a new relationship can be formed twixt doctor and patient as a package of care is built around their new found need. Almost always the patients are wholly undemanding, and would often rather have just been let alone in the first place, but again almost without exception they accept our “too little, too late” ministrations with good grace and a polite appreciation.

We tend to regard such patients as living in “denial” of their illness. I am increasingly coming round to the view that they are doing nothing of the sort. True, for some the diagnosis and prognosis come as a complete shock. But not many. Most have been well aware that “the game’s afoot” for months, if not years before coming to or attention. They have calmly taken the view that rather than be “prodded and poked” they will allow nature to take its course. Far from living in denial, they have been living in “acceptance”.

There is an art in caring for such cases that lies in laying out options, allowing fully informed choices to be made and then in stepping back and doing “just enough” to allow things to play out as they will. Caring need not always be synonymous with curing, and indeed in such cases seldom could it even if we wished it so.


Shinga said...

Hmm, so I gather that 'denial' is not sufficiently gnomic for the prize?

A family friend has a couple of elderly relatives who have taken a similar course. They felt that they were managing nicely, with the help of friends and neighbours, and had made a conscious decision that they didn't want to the poking and prodding that they'd seen others go through. There came a point when they were keen on some pain relief but didn't want anything beyond that.

Regards - Shinga

Doctor Jest said...

shinga-- spot on as ever. Perhaps I'm not as gnomic as I'd thought. Still Alberic in mind for the future....

getting back to business though foir a moment these sorts of decisions can be tough on the family left behind. It seems we all feel an imperative to "do something" on occasion, even when it is plain that that "something" is not welcomed. I hope your friend and their family felt well supported.

Shinga said...

Might I mention that my perception is that you owe me a shedload of virtual Hobnobs?

As for my friend's relatives, absolutely a good experience. A rural area, fabulous GP who had extensive knowledge of the community, knew what to offer and when, what would be acceptable and what wouldn't. Not averse to some decent pain medication and very willing to discuss dosages where people felt they were dosing too much or being knocked stupid. Both of the relatives were elderly, tremendously self-possessed and dignified: the GP talked through investigative and other options with them, made sure that they understood them and then accepted that they didn't want them. After that, he supervised their palliative care.

Regards - Shinga

Doctor Jest said...

Ooops. Yes indeed, well at least one of those 33% extra packs they're doing at the moment (or so I'm told-- I of course have staff for that sort of thing...).

Good to hear there are areas where "proper" doctoring is still allowed too.