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You can find the current article at its original source at https://www.theguardian.com/commentisfree/2018/aug/22/we-must-strike-a-balance-between-confidence-and-humility-in-matters-of-life-and-death
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| A dying patient asks could I have done more to save her – she is right to need an answer | A dying patient asks could I have done more to save her – she is right to need an answer |
| (4 months later) | |
| After many years of a firm and faithful association, the predictable has occurred. Her cancer has progressed, and she has gone from being a robust mother and devoted wife to a mere shadow of her former self, confined to her bed, in turn lamenting over and bewildered by how it has come to this. In hospital, my hand reaches out to her in sympathy and she clutches it as tears stream down her face. “Why, why, why?” The conclusions of scientific research whisper in my ears, “because it’s bad biology” but the consolation falls flat amid the visible devastation of illness. Our journey together has been difficult with the wins competing with the setbacks. | After many years of a firm and faithful association, the predictable has occurred. Her cancer has progressed, and she has gone from being a robust mother and devoted wife to a mere shadow of her former self, confined to her bed, in turn lamenting over and bewildered by how it has come to this. In hospital, my hand reaches out to her in sympathy and she clutches it as tears stream down her face. “Why, why, why?” The conclusions of scientific research whisper in my ears, “because it’s bad biology” but the consolation falls flat amid the visible devastation of illness. Our journey together has been difficult with the wins competing with the setbacks. |
| To treat or not to treat: find out what really matters to the patient | Ranjana Srivastava | |
| She is a battle-hardened refugee who is wary of everyone and everything. A life scattered across many countries in her still young life has left her completely traumatised and unable to separate one misfortune from another. She has witnessed a parade of doctors but each time has returned to my care despite the opportunities provided elsewhere. Somehow, she has found a modicum of faith in me, perhaps because I remind her of the person she could have been had it not been for the accidents of fate. She is fluent in her native language, and I understand enough of it to hear the word “trust” used genuinely and frequently. As if to make sure, her husband tells me in English at every visit, “she has great trust in you.” This level of confidence is many things but most of all, it’s onerous. | She is a battle-hardened refugee who is wary of everyone and everything. A life scattered across many countries in her still young life has left her completely traumatised and unable to separate one misfortune from another. She has witnessed a parade of doctors but each time has returned to my care despite the opportunities provided elsewhere. Somehow, she has found a modicum of faith in me, perhaps because I remind her of the person she could have been had it not been for the accidents of fate. She is fluent in her native language, and I understand enough of it to hear the word “trust” used genuinely and frequently. As if to make sure, her husband tells me in English at every visit, “she has great trust in you.” This level of confidence is many things but most of all, it’s onerous. |
| Now that our journey is at its end, I prepare for a familiar process, the complicated role of sustaining hope while telling the truth; honouring life while navigating death. It’s dealing with a thousand simultaneous conflicting emotions while staying on track. | Now that our journey is at its end, I prepare for a familiar process, the complicated role of sustaining hope while telling the truth; honouring life while navigating death. It’s dealing with a thousand simultaneous conflicting emotions while staying on track. |
| It’s tricky walking this line between the science and art of medicine | It’s tricky walking this line between the science and art of medicine |
| As I sit at the foot of her bed, her hand grasps mine and she suddenly asks, “Have you done everything?” | As I sit at the foot of her bed, her hand grasps mine and she suddenly asks, “Have you done everything?” |
| In her tone, I don’t hear rhetoric or reconciliation but a clear question: a dying patient querying the very choice of doctor and all the “what ifs” that came as a result. The question is gut-wrenching and renders me speechless. | In her tone, I don’t hear rhetoric or reconciliation but a clear question: a dying patient querying the very choice of doctor and all the “what ifs” that came as a result. The question is gut-wrenching and renders me speechless. |
| I watch her, struggling to take a full breath, surrounded by the paraphernalia of illness – a cupful of tablets, an uneaten sandwich, a social work referral, and I realise that we are at a watershed moment. In order to die well, my patient needs to believe that I did everything I could. In order for me to let go and continue to help my other patients, I need to believe that I did everything I could. | I watch her, struggling to take a full breath, surrounded by the paraphernalia of illness – a cupful of tablets, an uneaten sandwich, a social work referral, and I realise that we are at a watershed moment. In order to die well, my patient needs to believe that I did everything I could. In order for me to let go and continue to help my other patients, I need to believe that I did everything I could. |
| She’s too tired, so outside, I address the question of more chemotherapy which is always possible but would constitute futile medicine. Her husband mentions a new internet cure. I tell him that I don’t believe in it but won’t stop him from procuring it. Noting the relaxing of my attitude, he asks how long, something he has never asked before. Weeks, I reply, my heart sinking. He nods with understanding. | She’s too tired, so outside, I address the question of more chemotherapy which is always possible but would constitute futile medicine. Her husband mentions a new internet cure. I tell him that I don’t believe in it but won’t stop him from procuring it. Noting the relaxing of my attitude, he asks how long, something he has never asked before. Weeks, I reply, my heart sinking. He nods with understanding. |
| I watch him, tired beyond belief, a hero in my eyes for having carried such an unimaginable burden in his young life. Nothing worked out for them – neither the idea of a safe home nor a happy family, and certainly not good health. From the youngest to the oldest, they have all suffered. And yet, there is no one to blame but the vagaries of fate. Every community service has cared deeply for her and a cancer nurse has been her anchor. She has received continuous care from one oncologist and the inpatient service has always risen to meet her needs. For all this, they are exceedingly grateful. But still, the question that they keep returning to is, could I personally have done better? | I watch him, tired beyond belief, a hero in my eyes for having carried such an unimaginable burden in his young life. Nothing worked out for them – neither the idea of a safe home nor a happy family, and certainly not good health. From the youngest to the oldest, they have all suffered. And yet, there is no one to blame but the vagaries of fate. Every community service has cared deeply for her and a cancer nurse has been her anchor. She has received continuous care from one oncologist and the inpatient service has always risen to meet her needs. For all this, they are exceedingly grateful. But still, the question that they keep returning to is, could I personally have done better? |
| It can be tempting to dismiss this question as the necessary wanderings of a grieving mind but where life and death are concerned, one must constantly be on the watch against overconfidence and make room for reflection. Unsettled by her worry, I turn the place upside down in search of answers. I revisit every decision point, every conversation, every prediction, every sleepless night I spent. I ask other oncologists what they might have done – nothing different, they sympathise. I look for clinical trials which she is simply too ill for. Her nurse agrees she is dying. Finally, I turn to a palliative care physician who knows the patient well and reassures me that the best way forward is supportive care. | It can be tempting to dismiss this question as the necessary wanderings of a grieving mind but where life and death are concerned, one must constantly be on the watch against overconfidence and make room for reflection. Unsettled by her worry, I turn the place upside down in search of answers. I revisit every decision point, every conversation, every prediction, every sleepless night I spent. I ask other oncologists what they might have done – nothing different, they sympathise. I look for clinical trials which she is simply too ill for. Her nurse agrees she is dying. Finally, I turn to a palliative care physician who knows the patient well and reassures me that the best way forward is supportive care. |
| This advice and understanding starts to lift the fog of my loneliness. There is no “I told you so” moment but slowly, my churning dissipates and acceptance enters her lexicon, proving that the ritual has value for us both. The patient slowly reconciles with her mortality; I don’t feel complicit in the outcome. | This advice and understanding starts to lift the fog of my loneliness. There is no “I told you so” moment but slowly, my churning dissipates and acceptance enters her lexicon, proving that the ritual has value for us both. The patient slowly reconciles with her mortality; I don’t feel complicit in the outcome. |
| In matters of life and death, doctors must strike a balance between confidence and humility. Our patients die from their disease, but they also die due to error, negligence, arrogance, misunderstanding and miscommunication. To doubt one’s every move as a doctor would compromise patient care but to never question it at all would be folly. It’s tricky walking this line between the science and art of medicine but we must give ourselves permission to air our doubts, ask for help, and never put our presumptions ahead of patient welfare. More than reaching a diagnosis or knowing what drug to prescribe, this is the hardest part of being a doctor and the entire culture of medicine is helped by acknowledging this. | In matters of life and death, doctors must strike a balance between confidence and humility. Our patients die from their disease, but they also die due to error, negligence, arrogance, misunderstanding and miscommunication. To doubt one’s every move as a doctor would compromise patient care but to never question it at all would be folly. It’s tricky walking this line between the science and art of medicine but we must give ourselves permission to air our doubts, ask for help, and never put our presumptions ahead of patient welfare. More than reaching a diagnosis or knowing what drug to prescribe, this is the hardest part of being a doctor and the entire culture of medicine is helped by acknowledging this. |
| Cancer: one in four too scared to seek medical help over symptom | |
| My patient insists on going home, and every possible help swings into place, as if to say we will do whatever it takes. On the heels of her departure, I take an urgent call about a different patient - one who’s cursed by the worst disease of all, absolute loneliness. I have personally spent hours with him in discussions about the end of life, not to mention those held with palliative care providers. | My patient insists on going home, and every possible help swings into place, as if to say we will do whatever it takes. On the heels of her departure, I take an urgent call about a different patient - one who’s cursed by the worst disease of all, absolute loneliness. I have personally spent hours with him in discussions about the end of life, not to mention those held with palliative care providers. |
| “I hate to say it, but the patient has no idea about his prognosis”, says his social worker. On the back of my deliberate efforts and the patient’s repeated denial, my frustrations threaten to explode and a protest rises to my lips. But it’s one of those weeks, and the social worker is only doing her job, so I swallow the protest and simply say to her, “We will bring him back but this time, why don’t you come too, so you know exactly what’s being said?” | “I hate to say it, but the patient has no idea about his prognosis”, says his social worker. On the back of my deliberate efforts and the patient’s repeated denial, my frustrations threaten to explode and a protest rises to my lips. But it’s one of those weeks, and the social worker is only doing her job, so I swallow the protest and simply say to her, “We will bring him back but this time, why don’t you come too, so you know exactly what’s being said?” |
| Her voice fills with relief. “That would be just great.” | Her voice fills with relief. “That would be just great.” |
| • Ranjana Srivastava is an oncologist and Guardian Australia columnist | • Ranjana Srivastava is an oncologist and Guardian Australia columnist |
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