17 August 2023
My first time.
1 May 2020
Who was the first patient you discussed their own death with?
For me, it was my grandmother. I was a medical student and she was slowly declining from heart and renal failure. During her last admission to hospital, she was clearly fearful of impending death – she told me that she felt better when I sat with her as she slept – which she did more frequently than, previously – as she feared that she might not wake up from her nap.
I assume that the medical staff noted our relationship. It was suggested to me that I might discuss resuscitation orders with her. I agreed that this was a timely discussion for her. Having participated in resuscitation during my rotation in the Emergency Department wanted to spare her this futile treatment.
I can only imagine how bumbling I was in that conversation. My mother had noted when I started medical school that I would have to work on my “bedside manner”.
I definitely lacked the requisite vocabulary to not frighten her more. However, I do remember trying to reassure her that this was to prevent harmful treatment, that wouldn’t help her. And I would have loved to have had the phrase “It’s an order so that we hold your hand when you are dying rather than pound your chest”( see here2 and here3 for more).
I would have loved to have known better to narrate the process of dying to her; to relieve her of her fear that slipping away would be painful and something that she should fight. That her increasing need for sleep was normal and it differed from slipping into unconsciousness so that she could sleep more easily.
In the end, I failed her. As her medical team predicted, she had a cardiac arrest watching a soap on TV a few weeks later. And I failed her, because I hadn’t had that delicate conversation with her wider family. In my naïve medical student approach, she was the patient and I and the medical team knew her wishes. But I forgot that she existed surrounded by a devoted family who wanted to keep her forever.
She arrested, panic ensued, an ambulance was called, CPR was commenced and she had cardiac compressions en route to the hospital where she was pronounced dead. Family members arrived to the resus bay to sit with her and hold her hand. With better communication, we could have done that in her own home.
What I wish I’d known
In the world of surgery, we are always learning4. I regularly wish that I had already mastered all of the communication skills that I need. In a recent blog post1 I wrote about an approach to end of life communication entitled “Difficult Conversations – Why we need to talk about dying”. Dr Lara Mitchell has produced resource materials with Open Change, an educational design company, to give healthcare professionals a visual approach to support these difficult conversations around dying with compassion and honesty. It aims to give framework, concepts and phrases to support these conversations for health and social care.
She has now produced a video discussing the framework in more detail and with references to other sources5. I found it useful and hope that you do too. In the meantime, I’ll continue to work on my bedside manner, aiming to communicate with openness, compassion and empathy.
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