Friday, January 15, 2010

"Badges, badges?.... "

Yes it's complete the quote time on the old caseblog again. The above comes from one of my favourite movies, see if you can come up with the line that follows, whilst I tell you a tale of woe.

Mac' was in his seventies, and was a true Celtic patriarch. He had a large family and they in turn have gone off to have large families of their own, but most have not gone that far away, so their tight knit "clan" is always on hand to gather round in times of adversity. A few years ago Mac' developed a malignant disease, and it was treated, but by the time it had been staged it was on the cards that it had spread and would be reappearing sometime, somewhere.

(Cleverer docs than your humble interlocutor have ways of telling this, by looking at the histology of the "primary" tumour, the degree to which it has invaded the surrounding tissue and the extent of involvement of lymph nodes nearby for example.)

Late last year Mac' developed some tummy trouble and a little pain. Shortly after this he developed jaundice, and it was pretty clear that the disease had come back. He had a couple of speedy consultations with the oncologists, and started treatment which he and we all knew to be palliative. The clan duly gathered, and it was plain that he was going to be well supported and cared for, and we slipped into an easy routine of checking in now and again to see all was well, and letting him steer his course through what we all knew, but never said, was to be his final illness. This was his choice, and we worked hard to respect it.

There are times when you really don't need to ask a question to know the answer. Mac's whole demeanour and approach to his symptoms let us know he knew he was running out of time and really wouldn't appreciate us jabbering on about it. He wanted to get on with living his final days, not confront what came after. In his last week he finally had to admit that there was a little more pain that he was willing to put up with and accepted the offer of a morphine syringe driver to give him small regular trickle doses of opiate, rather than having to rely on intermittent administration of oral medication.

At the time of his recurrence he was introduced to the "Badge Nurse" who looks after terminal illness. From then on he had little to do with them, really neither needing nor wanting their input. Still we are supposed to offer "Gold Standard" care these days and so the badge nurse took it upon themself to visit from time to time. Returning for the first time in a month just after New Year, said nurse, noting the deterioration, pointed out rather too bluntly to Mac' that he was not long for this world. The "clan" politely thanked them and showed them the door.

Twenty four hours later Mac' had died.

He was ready and had no need of the information. What should have been an elegant decline into the everafter has been marred for his remaining family and they are profoundly unhappy. Still at least our "Badge Nurse" can tick a box on their "Gold Standard" protocol :-(


alhi said...

Treasure of the Siere Madre.

There's telling it like it is and knowing when to shut up. At least the family showed the nurse the door.

Doctor Jest said...

alhi-- it really should be shouldn't it, but I'm afraid I'm not that high-brow. The line was "quoted" in another later movie.

"...and knowing when to shut up." Sadly not something that fits easily into a Protocol, which is why we here in GPland still greatly prefer Guidelines. The problem is to many of our Nurse colleagues, especially those employed by non-GPs, even Guidelines get treated as though they were Protocols :-(

alhi said...

Not Blazing Saddles?

Nikita said...

"Blazing Saddles". I think for the second.

The problem is not just confined to nurses I am afraid. My husband requested not to know his diagnosis and this was respected by our then family GP. Now, as the practice has changed hands and is run by doctors who don't really 'know' us, every time I make a appointment for him, I have to go beforehand and impress that he does not want to know. I have asked for this to be highlighted on his notes somewhere.

The look of alarm on my face when the GP begins to say ...... usually seems to act as a memory jogger.

Doctor Jest said...

alhi / nikita-- you got me ;-) well done both. Nikita, sorry your new docs seem so slow on the uptake. Also sorry to hear of your husband's illness.

Good wishes to you all.