Columnist Dr Shaba Nabi fears doctors’ lack of time means drugs are replacing holistic care at the end of life
Being faced with a dying patient when working as a busy on-call GP evokes feelings of both heartsink and reward. Heartsink, because we know the duty screen will start piling up while we navigate our way through a life that we have not previously touched. We know that providing comfort to those reaching the end of life is one of the few areas where we can make a positive difference to our patients, so why does it all feel so robotic?
End-of-life conversations could be the pinnacle of good communication, as we understand a person’s values and what matters to them most. Yet we don’t have the chance to practise these essential skills as frequently and in as much depth as we would like, due to the pressures of our workload.
So, when my duty screen flags up that an 89-year-old woman may be nearing the end of life, instead of thinking about providing her with holistic care, I worry about retrieving the F12 protocol, which will write out all the end-of-life care drugs for me.
But on this recent occasion, I didn’t reach for my prescription pad. Instead, I decided to understand the world of the patient and what her relatives thought she wanted. Fortunately, her daughter was accepting of her demise and had no unrealistic expectations about intervention. As her mother appeared comfortable with no agitation, I opted to convert her small dose of codeine to a low-dose opiate patch to maintain a background level of analgesia. I later found this was not recommended by palliative care prescribing guidelines, but a shared decision-making dialogue with the patient’s daughter, led to this approach. Although this conversation took significantly longer than a brief instruction about just-in-case medications, I felt momentarily content that I had practised according to the family’s values.
As expected, the duty screen had multiplied, and I didn’t give the patient another thought until her death notification came through. Curious about the outcome of my on-call decision, I noticed she’d been prescribed a syringe driver full of drugs at the request of the community nurse team, a day after I’d spoken to her daughter. It is possible that she had become distressed or agitated, but it made me reflect on all the deaths I have seen in my lifetime, professionally and personally.
In the earlier part of my career, it was common to prescribe syringe drivers for patients dying of cancer, but not for those dying of frailty in old age. In the same way that CPR is futile if organs are naturally failing, one would assume this type of death would also be a natural fading away, without the need for extra drugs.
Perhaps I am swayed by the experience of watching my mother die three years ago. Her GP also converted her arthritis pain relief to a patch, but no other medical intervention was needed and she died peacefully in her own home, surrounded by her grandchildren singing to her.
Is the chemicalisation of the ageing process and death a response to the lack of time and spiritual support? It is much easier to sign off an automated prescription than to explore symptoms and values. And if you don’t have a loving family keeping vigil at your bedside, the most humane action may be to obliterate any fear or emotional pain using chemicals.
But given our lack of time, and in the absence of any certainty around end-of-life comfort, I guess it’s hard to justify any other approach to alleviate potential pain.
Dr Shaba Nabi is a GP trainer in Bristol. Read more of her blogs here
This blog was originally published in Pulse’s September issue
READERS' COMMENTS [4]
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Noted, but if you are stuck with delirium or terminal agitation on a Sunday evening just in case medication are invaluable.
Little bit glib, isn’t it? “The chemicalisation of death”, when in both the other situations you have mentioned, existing medication was converted to a transdermal… chemical. That said, there is a general refusal in the public to accept that people all die from something, but I do think that ensuring someone has a ‘good’ death is a vital part of our role.
It is indeed getting harder to deal with these interactions, especially as a locum, because, I feel, the gradual progress of involvement is no longer occurring even for full-time principal GPs. It is not the short time for the last couple of days so much perhaps, but the lack of involvement in the last few weeks, months, or indeed hardly at all in the last few years.
These used to be patients we would know fairly well, and already know their chacters, wishes, and resources, and also, we would have available to us a wider stock of suitable drugs in various forms that we could use in various ways supported by interventions by ourselves and our wider team.
But now, if there is not a ‘Just in case’ box pre-prescribed for the named individual, with the ‘correct’ contents for the standardised ways it is used, not only do we have little availability of any stocks, but we cause increased anxiety and stress in those who have come to depend on standard ‘JIC’ availability.
The strive to get and keep people away from patches due to expense, means we cannot think of it until the last minute, and absorption is so slow to reach steady state, and possibly reduced unpredictably by terminal decline, that we cannot rely on predictable levels of effect, but that applies to superficial syringe-drivers as well to some extent.
Systems are less suited to terminal care than they were once, despite ‘improvements’, and the lack of time and increase workload pressures certainly do not help, but perhaps our main problem is indeed the change in attitudes to allowing people to die.
Last-few minutes attempts by the dying to get to talk to a family member, or hold their hand, or simple needs are interpreted as agitation: They certainly become agitation when they are misinterpreted by bystanders as an indication of need to step up the level of medical intervention, rather than make the wished-for adjustment in social interventions : it is not only doctors who are pressed for time, but these days it applies to family and carers also, and it does not help serve our needs well for a ‘good death’.
Hi Shaba
Yes I agree that in a perfect world it might be great if every EoL patient could have a regular lengthy GP consultation to make a holistic assessment of any changes in their needs.
But I think your article undersells the value of the standardised EoL medication pathways. Do you remember what it was like before they existed? Scrabbling around the early chapters of the paper BNF, trying to work out starting doses and interactions?
I think that the creation of standardised medication pathways is one of the real advances in EoL GP care in the last decade or two. While they may not help everyone get the ideal individualised treatment, they make it much less likely that patients are left with no treatment when they need it.