Terminal Choice

It is Thursday evening, around 8pm, and I am based between our triage area and minors.  This involves providing advice and oversight for all the patients who are being brought in by ambulance and have symptoms that may represent serious illness in triage, as well as assisting our team who are assessing and treating patients with minor injuries.  There is a lot of activity to try and have eyes on, and I am, as always, heavily reliant on our excellent nurses and doctors in training to raise issues and concerns that may require my slightly more experience to resolve. 

One of the challenges is knowing when to consult and when to dive in.  Staying slightly removed from individual patient care allows you to have oversight of the Emergency Department and encourages better command of the various resources and overall performance of the unit.  Committing to take over the care of individual patients can often lead to a good interaction with that patient, but can come at the cost that other patients may lose the opportunity to have advice sought regarding their conditions.  At this time of the day, we may have upwards of 70-80 patients of all flavours in the ED, and we are often still receiving 30 plus patients an hour through the door.  Balancing this depth of involvement can be an art in itself.

Jen is co-ordinating triage and calls me over:

"Dave, would you quickly see this epistaxis?" (Bleeding from the nose).

This is a slightly unusual request, and I probably make a slightly quizzical face as she adds:

"It doesn't seem straightforward..."

So much can be said in so few words, and, as is often the case, she is spot on. 

I walk into the cubicle, knowing that there are 10 more in the queue for triage, and with the gentle tolling of an alarm bell ringing in the back of my mind.  I put it all to one side.  Jen would not have asked me to dive in if she didn't think it was a good use of my time, and I trust her to interrupt if there is a disaster elsewhere that may need my attention.  I am met by a man in his 50's who wears the signs of some recent bleeding from his nose, plus his wife who is looking particularly anxious, and their son, in his 20's, looking, I suppose, determined and slightly bullish.

Hello, my name is Dave and I am one of the Consultants.  What can we do for you this evening?"

I meet Bill, Rachel and their son Greg.

It turns out that Bill has a particularly aggressive cancer of his palate.  He has spent several months undergoing treatment from specialists to reduce the size and spread of this cancer, but, as of a couple of months ago, he has unfortunately reached the limit of what medical science can offer him.

This cancer will kill him.

This reality is shared very calmly and rapidly with me, and the whole family unit seem, perhaps not at peace, but at least accepting of this inevitability.

They go on to describe the events of earlier in the evening, when suddenly Bill started bleeding from an area in the nose where the tumour had invaded. 

"It was like a tap turning on." As they describe the flow of blood from the nose.

This lasted for maybe 20 minutes or so, soaking a couple of towels and filling the base of a small basin, and with direct pressure to both sides of the nose for a good 15 minutes, it seemed to stop almost as quickly as it had begun.

This is a small morsel of good news - the bleeding has now been stopped for an hour or so.

I ask them to talk through their treatment so far whilst I check Bill's pulse and blood pressure (acceptable), and I confirm in the Electronic Patient Summaries that there are indeed treatment options left open for Bill, only supportive measures - blood transfusions and pain relief - as required.

"Normal" medical procedure now would be to take some blood tests off Bill, check his haemoglobin, clotting, pre-arrange a blood transfusion, perhaps some liver function tests and electrolytes, observe him, maybe speak to one of the ENT (Ear, Nose & Throat) team, perhaps transfer him to their unit (in St. John's Hospital), etc.  All of these seemingly normal activities seem devoid of purpose if there is no definitive chance of improving Bill's wellbeing.  So I ask Bill and his family:

"What do you want to happen tonight?"

There is no hesitation in Bill's response:

"I want to go home.  I want to be at home.

A pause.

"I want to die at home."

Rachel looks deeply concerned.  Greg smiles wryly, his father's son.

I look to her, inviting her to share her thoughts:

"What if he bleeds again, what do we do... what if it won't stop?"  She is feeling the burden of care, the weight of responsibility for her husband's wishes, and of impending loss.  It is devastatingly heavy.

This brave family are in that increasingly rare moment when they know the end is near, and yet still have the capacity to choose the place and preferences that matter most to them when the time comes. 

Greg takes his mother's hand:

"We can make it work, we can use the bath, or something.  I'll be there.  We can do this."

We spend another 20 minutes talking through the possible permutations, and in that time all I do is help the family to make the right decision for Bill.  They can always come back to the ED if it gets too difficult or scary, but something tells me they won't.

They head home, with the lightest of medical touches proffered, and it may have been the most valuable clinical task I undertook that shift.