Friday, 30 December 2011

The Hospice


This week I spend a few days working in a hospice as part of my oncology rotation, which is a fantastic experience, being completely different to how I expected. I also attend a gynaecological cancer clinic, which is a long drive away, and spend a day in a GP practice where my assigned GP wants me to run the consultations. I am not sure if I am ready for that here at all, despite doing effectively the same thing in Tanzania all on my own...

The visit to the hospice is intended to let us get some experience of... well.. hospices. The medical school is very keen on showing us lots of out-of-hospital medicine, and I agree, I think it is a good idea to see as much of the varied world of medicine as possible. Not just to let us to plan our careers, but to help us understand how each speciality works when we are specialists ourselves. It is unlikely that a surgeon will be visiting hospices to learn about them once working, but could be referring patients to their care.

The hospice was lovely, and very different to what I had expected a hospice to be like. I have no idea why, but I had imagined  a hospice to be a little like an old people's home, with dying people sitting in their rooms, or if they could manage it, in large chairs in a circle, not doing very much. This perception was proven wrong from the moment I stepped into the warm, friendly and very professional reception. No strange and stuffy nursing-home-esque furnishings here. The staff were very friendly and accommodating, and despite the clinical feel to the building (I suppose it plays many roles similar to a hospital) it felt a lot more... fuzzy? We had talks from doctors, nurses, volunteers, carers and patients and talked to a number of patients who had come here. While we were learning about the different pain killing medication that was prescribed, we were asked if anyone wanted to try out one of the sublingual tablets. They said 'morphine' on the packet, but we were assured they were placebos. No-one seemed interested, after his talks on their sometimes nasty flavour, but he then said that they were wild berry flavour. Sounds delicious, right? I thought so, as I volunteered straight away to have one. Having put it in my mouth (don't worry, they did turn out to be placebos) there was just a bit of a bitter taste, and certainly no wild berry flavour... It also lasted for over a minute, rather than the 10 seconds to dissolve that he had taught us. I asked him about the flavour, and just said "yes, well, I lied... Otherwise no-one would have had one!" Are doctors allowed to lie?

Sublingual tablets do a similar job to the "pain killing lollipop" that Jade Goody was often seen sucking, which is meant to provide pain killing medication through the mucosa of the mouth.

I had always assumed that hospices were for people who were dying, so they could spend their final days (should they be too ill to go home) in a nicer environment than a hospital, while still receiving the same standard of care. This is one of the roles for the hospice, but it also fulfils many other roles as well. Many of the patients who I saw were not there 'to die', rather because they were ill, and needed somewhere to be cared for carefully for a month, but not so ill as to need to be in an intensive setting such as a hospital. The hospice is a much nicer environment, so attracts this sort of care. Unfortunately the hospice is also not NHS run, but still free to patients. It has about 20% of its cost paid for by the NHS, with the remaining cost sought through fund raisers and donations. I remember as part of the RAG at my medical school a couple of years ago, dressing up in a giant mascot costume and fund raising for the hospice at a shopping centre with some other students in scrubs. Fantastic fun, until the whole thing became far too hot. While I was at the hospice, they had had to close their activities centre, which was a big sociable room where those staying there could relax, talk, and partake in activities organised for them (yes, I know it sounds a little like a nursing home!) All the patients I talked to were very sad about this, as they enjoyed these sessions, but when the hospice is run as a charity, there is no guaranteed income, meaning that these sort of closures sometimes need to be made in order to keep the more essential services running. Hopefully the NHS hospitals don't see its relative cheapness (as it doesn't use NHS money) as a good excuse to put patients there to save themselves money. Hopefully this wouldn't happen, as those who would make these decisions will be far removed from the money aspects. 

Moral of the story: Charity run hospices are wonderful, donate to your local one!

The gynaecological cancer clinic was, unfortunately, a long way away from the hospitals we normally work at, and my accommodation. Fortunately I have a car, and motored us over there. It seemed a little but pointless to go such a long way for 3 hours worth of consultations, but I suppose to fit us into the timetable they need to branch out. Fortunately it was a very worthwhile clinic, with a very good consultant and registrar running the appointments. Unlike the palliative care clinic, there was a lot less bad news, and a lot more patients who had low grade cancers, with the doctors mostly aiming for a cure for most patients. There were a few patients who were not expected to be cured, and were being treated palliatively with treatments such as radiotherapy, to slow the cancers progression and reduce some of the nasty symptoms they were getting. What impressed me most was the fact that all of these patients were well aware that they had an incurable illness. There didn't seem to be any secrets that the doctors were keeping from the patients, and if the doctor was worried that the patient was not curable, the patient would know as well. I don't know what I was expecting, but such upfront honesty and openness with the patients just felt right.

I also get to do GP placements every few weeks in this year, where I spend a day in a GP's surgery in a sleepy country village. I am fortunate in that this is the same GP surgery I spent some time in in my first year, with the same doctor. She is very friendly, informal, and nice, and I am very pleased to have been placed back with her! The surgery is a large polyclinic, so I hope to get a lot of experience in a lot of different fields. We saw about twenty patients over the course of the day, the appointment times being a lot longer as I was there to take up the time. Normally GPs can see about 30-40 patients in one morning! The doctor wanted me to run the consultations, with her able to step in and ask supplementary questions, but I didn't think this would be a very good idea. I don't remember a lot, and felt I would like to see a few before trying them for myself. She seemed to understand, and I participated by adding in questions when she asked me - a much less worrying start! The patient who stood out most in this day was a large man who looked just like Hagrid from Harry Potter who had broken his leg.

The patient's beard and clothing matched Hagrid's almost perfectly. If he wasn't so serious, I would have thought he was joking around.

This man had had a real alcohol problem, put on a lot of weight, and the drunkenness, coupled with the poor vitamin intake from the lack of food had caused him to fall down the stairs. At the moment he couldn't leave the house because of his obesity and broken leg combination (some carers had come to bring him to the GP surgery), and all of his shopping was being done by a well meaning neighbour. This neighbour was sensible enough not to buy this man any alcohol, and for the last month he had not had anything to drink at all. He confessed that although the first week was very tough, he now felt a lot better because of it. A broken leg turning out to help someone out was quite interesting, though unfortunately he confessed that as soon as he could walk on the leg again, the first thing he would do would be to go down to his local and get himself a "pint or twelve". The GP tried hard to convince him not to start drinking again, but he wanted to. Without the patient making the decision themselves that they want to give up, it is unfortunately just not possible to get them to stop any harmful behaviour, whether it be smoking, drinking, other drugs or just plain over-eating. 

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