Monday, January 2, 2017

A Difficult Conversation

I didn't make a new year's resolution this year. Mostly because any previous ones I've made, go out the window within a couple of hours. Also, my go to "stop being fat" resolution is already being attempted as I've been on a "healthy eating" kick for 5 months or so already. However if I were to make a resolution, other than blogging more, it would be to spend my free evenings not on social media but reading the increasing pile of books I have accrued over the last few years. The pile ever increases because whilst I buy around a book a month with good intentions, I probably only get through 1 every 2-3 months. There are currently a range of biographies, GoT novels, political polemics and other books building up on my bookshelf. I'm so terrible at keeping up with it that I purchased Paul Mason's "post capitalism" twice as I forgot it was already in my "to read" pile. I guess that illustrates the inherent waste of consumerism he is trying to get at; I don't know, I haven't read it yet!

Anyhow, I started as I meant to go on and picked up Atul Gawande's "Being Mortal". I thought this was a safe place to start as his other book I read "The Checklist  Manifesto" was so good it changed the way I worked in the operating theatre. Going from sighing my way through the WHO checklist to making it a central part of being in theatre. Gawande is one of those people who seems to be able to do anything. An accomplished surgeon, writer, NGO and public health leader. In fact if he played for United he'd be the picture at the bottom of this blog!

Its about how medicine has changed the way we experience ageing and death and the things people around America are doing to try and improve this situation. He tells a story of not wanting to confront a young patient's impending death from lung cancer by using euphemisms, and how difficult it was to actually bring up the subject for the doctor. Instead talking about "putting this issue aside so we can focus on the lung cancer". This resonated so much with my own experience of  these conversations and I had an example where I ended up having a difficult conversation, in a situation you wouldn't normally expect.

The junior doctors usually have the job of clerking in elective patients for day case procedures. Usually it's a quick chat, write up their regular medication and make sure their consent form and blood tests are up to date. This case was unfortunately a young patient with advanced ovarian cancer coming in for an ascitic drain to relieve the discomfort of having fluid build up in her abdomen. Her cancer was incurable and she had tried 2 types of chemotherapy without success already.

I duly went through her medical history and medications, which were surprisingly few for someone so poorly and noticed she was on a statin. A statin is a drug that lowers cholesterol and can help prevent strokes and heart attacks if given to enough people over a long enough time period. The patient told me that they gave her nausea but stuck with a low dose because it was good for her in the long term. This is right, but things had changed since she started on her cancer journey.

The easy thing to do would be chart the statin and get on with things but I asked if she wanted to carry on taking the medication. I struggled to find a way to say "why take a drug that makes you feel ill and won't help you because you'll be dead from your cancer before you get the benefit of the statin" without sounding horrible. So I tried to see what her understanding was about statins, and she seemed clued up and then seemed to stop and then was to the point for me:

"The cancer will get me before a heart attack will, won't it?"

I gave a non-comittal grimace and suggested she could stop it to see if it helped her nausea. She stopped the drug and when she came back a few weeks later for another drainage, she told me she felt slightly better from a nausea point of view. It showed that having difficult conversations are actually be worth it for patients and we as doctors tend to practice with inertia (especially if another doctor started the medications). Helping patients make sensible decisions about preventative medications is a small part to play, but showed tackling these may help in the long run.

So, just like the Checklist Manifesto changed my operating pratice,  it looks like Gawande's next book will change how I practise medicine in patients who are terminally ill.

Oh, and if anyone wants a copy of Paul Mason's Post Capitalism, I have a spare!

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