Estimating when someone will die

Hi,


This week I attend what I thought was a breast cancer clinic, which turned out to be a palliative care clinic, and very sad. I also go on a ward round with the haematology team, who see a lot of blood based cancers as part of their work. In my second week back in medical school, and I have quickly gotten used to the differences. I suppose it is all about what you perceive as 'normal'. The time in Tanzania had me seeing that as almost 'the norm', and coming to the UK had me in some kind of culture shock at seeing how different the healthcare is. This sounds a little drama-queen-ish, but to a mild degree, I think it is true. Now I am used to the UK healthcare, I don't spend my time looking at things twice, or being impressed by a consultant going the extra mile. 


The breast-cancer-turned-palliative-care clinic was the highlight (in some respects) of the week for me. I had been expecting a clinic for those with breast cancer, so had read about breast examinations, important points in the history, and other useful information. Any clinic where cancer is dealt with isn't going to be a walk in the park emotionally, but I wasn't expecting anything mind-blowingly upsetting, as breast cancer tends to have relatively good cure rates (better than many cancers). On my arrival, the clinic turned out to be a palliative care clinic that was focussed around lung cancer. This will make it a lot more upsetting, as it means that only patients who are dying will be seen, rather than everyone. Lung cancer also has a much worse prognosis than breast cancer, progressing faster and with much more likelihood of being incurable.


I was sitting in this clinic with one other medical student and the palliative care consultant. She warned us before it started that some of the patient's cases can be very upsetting, but it is good to see these sort of things as a medical student, and important to come to terms that not everyone can be cured by modern medicine, and am important part of medicine is letting people die comfortably. The first patient who we see is a ex-service man who has come in with his wife, with advanced lung cancer. The cancer has spread to a number of sites in his body, such as the liver and the bone, causing a variety of problems and pains which he wants the palliative care consultant to help him with. This involves a discussion about pain killers and other palliative medication, which is relatively emotionless, as it is all factual. The emotional talk comes later, after the man asks how much time the doctor thinks he has left to live. This is a question that doctors do not like to answer, as it is very hard to tell, and whatever answer they give can make huge impressions on the patient's life. It is possible, though, for the doctor to take a wild guess. The general rule for guessing how much time the patient has left is to look at the frequency with which new symptoms are appearing. If new symptoms (from the illness, such as ascites or bone pain) are appearing at a few a month, then the patients life expectancy is likely to be measured in months. A few a week means it is likely to be measured in weeks and if they are appearing daily, then its likely that the patients life expectancy may be measured in days. This can be very inaccurate, and everyone has heard of doctors giving patients weeks to live, who then turn out to live for years. Despite this inaccuracy, it is fair to give a guess (making sure the patient is very aware that it is only a guess) as to how long the doctor feels the patient may have if the patient asks. You cannot exactly say you will not tell them!


Getting back to the point, when the patient asked the doctor how long he had left to live, in a tactical and roundabout way, his wife started crying, pulling at him towards the door and telling him he should ask such things. He told the doctor that he really did want to know, and the wife started sobbing hysterically, trying to pull him to leave. I decided that this is when medical students can actually be of some use, and take the crying woman by the arm (kindly, I am not dragging her) and lead her out of the room to the waiting room. I chat with her there for 10 to 15 minutes about what she is worried about (I volunteer for Samaritans in my free time, so have had plenty of training for these sort of talks), until the consultant comes along to find me, telling me that there is actually a quiet room for this exact sort of situation, rather than me taking them to the waiting room where there are other patients. I am a bit embarrassed, but take the wife to the quiet room to keep talking, while the consultant goes to finish her consultation with the patient, after checking that the wife doesn't want to return to the room ("definitely not!"). The wife thanks me profusely before leaving, and I feel as though I have been useful, an unusual feeling as a medical student! After the consultation, the other medical student (who had remained in the room) told me that the man seemed to be taking his coming death a lot better than his wife, and once she had left the room had confessed that his biggest fear was how she would feel when he was gone, or very ill at the end stage of his illness. The consultant estimated him to have some months left, though as I said before, this can be very inaccurate, and the patient seemed to accept this.


We see about ten patients in the morning, and despite the fast throughput, the palliative care consultant seems to give each patient as much time as they want, giving them time to talk about their symptoms and the progression of the disease (the reasons for them coming to the clinic) as well as the much more difficult touchy-feely issues around the fact that they are dying. The patient who made the most impression on me was a lovely mannered kind old man who had a very horse voice when we were talking to him. In the first couple of years of medical school, this is taught as one of the signs of lung cancer, as the cancer is affecting the left recurrent laryngeal nerve. This horse voice had only come on in the last week, and was the reason for his visit. It suggested that his lung cancer was progressing (I.e. it is getting bigger, hence why this nerve is now involved) despite the fact that he was currently on chemotherapy). The conversation was based around the fact that, seeing as this was his third different drugs combination, and they all had not worked, it might be a good idea to stop chemotherapy and come to terms that the cancer was not curable. The man seemed to accept this gracefully, and seemed to have been expecting such a statement from the doctor. I found it a lot harder, however, and found myself feeling really upset that this gentleman could no longer be treated, and the fact the treatment was being stopped seemed as though we were 'giving up' with him, and consigning him to death. I know this is not the case, and the fact he was at the palliative care clinic meant that he wasn't being given up on, but this is something that is very important in modern medicine, as everyone dies, but something I know I will struggle to come to terms with.

As can be seen by this anatomy diagram, the left recurrent laryngeal nerve runs under the arch of the aorta, and hence can be affected by grows in the lung. The right doesn't descend as far, and is not affected.

At the end of the clinic, the consultant took me aside to thank me for dealing with the wife I mentioned in a "professional, yet lovely" way. She said it made it a lot easier for the husband to talk about his illness, without her having to ask the lady to leave. She also told me to try and forget about the emotions I experienced in the clinic, instead taking away the knowledge I gained about the conditions I saw, and the service that is offered. It is always good to feel valued, and I think she must have been able to tell that a few of the patients had left me feeling upset.


The haematology ward round that I participated in later this week was a much more positive affair. There were a lot of patients with blood cancers, and all of the patients we saw had good prognoses, with the doctors aiming to cure all of them. Blood cancers are much easier to treat. Some of the patients were in special side rooms, and we avoided going in with the essential doctor and nurses, as the treatments for these cancers can often leave patients with a very poor immune system, meaning it is important not to expose them to infections. My favourite patient on this ward round (I am not sure if we are allowed favourite patients...) was a lady who, as a side effect of her treatment had had a nasty fall down her stairs, and because of her slatted metal bannisters, had torn off a lot of the skin from both of her arms. She was otherwise pretty well, and charming and chatty, so I went back later to talk with her some more. She had her arms wrapped up in two huge bandages around cotton wool, and I asked her if they were inconvenient. She said that the nurses and doctors had offered to change them to something smaller a number of times, but she preferred them like this. She had always gotten cold arms in the past, but now they were always so toasty warm!