Breaking and Mending Read online

  ‘This is Dr Cannon,’ I said, still testing out the shape of the words.

  ‘Could you come to the ward and certify a death,’ said the voice on the other end of the telephone.

  It was a rubbish first job. I could think of many more jobs I would rather have been given, but I presumed it would be fine. My training, after all, had prepared me.

  At medical school, we are taught very little about death. We learn many things about the dying process, we read textbooks about the mechanics that lie behind our final breath and the pathology of the diseases that will eventually kill us all, but we speak very little about death itself. There is a space. A space between an illness claiming its victory and the correct way to fill out a death certificate. A space that contains relatives and upset, chaos and reflection. A space that very often contains pieces of our own self-doubt.

  Up until that first day as a junior doctor, I had never met death outside of my own family, other than in the detached, leathered cadavers of the dissection room and in the neat rituals of a post-mortem. As a medic, I had never found myself face-to-face with the end of someone’s life, at least not one that didn’t rest quietly upon a stainless steel table, but still I went to the ward on that day to fulfil my first task as a junior doctor feeling more than prepared for the experience.

  And I did know how to feel for a pulse and how to look for signs of respiratory effort. I did know how to check for the presence of a pacemaker and fill out the death certificate. I had been taught all of this, and I could deal with it.

  But what I couldn’t deal with, and what I didn’t know, was how I would feel walking into a room at the end of someone’s life and seeing all the small details around that room that told me who this person was. The small details that told me this person’s story. The bag of knitting and the get-well cards, the half-eaten packet of Polo mints and the puzzle books. It was the paperback on the bedside table that stayed with me more than anything else. Closed shut, its bookmark resting for evermore halfway through a story. I took the sight of that paperback and kept it with me. It joined other small details I collected on the wards as I went through my days, not realising that it was the weight of these details that would eventually break me.

  When I arrived on the ward to certify the death, I collected a pair of latex gloves from a box on the wall, and the rest of the bay watched as I disappeared behind the curtains that were drawn around the patient’s bed.

  I didn’t know the patient. I had never spoken to her or been involved in her care, I just happened to be the doctor on call that day, and I just happened to be the one who was summoned when she passed away. As I worked, I could hear the sound of the rest of the ward, as it played out just beyond the paper-thin curtain. It seemed uncomfortable, brutal almost, that ninety-two years of life could finish to a soundtrack of meal trolleys and floor cleaners, and the whirr and click of visitor conversation. When I’d finished everything I had to do, I removed my gloves and I paused. I looked around the cubicle for something else, another task, but everything had been done. Still, I waited for a moment. As a doctor, my duties had been fulfilled, but as a human being I felt as though the end of someone’s life needed to be observed in some way. It felt impossible to turn on my heels and just go, and throwing my gloves into the nearest bin and getting on with my shift seemed strangely dismissive of the long life that had just ended right in front of me.

  When I finally left the cubicle, the eyes of the ward remained upon me. I glanced around as I drew the curtains closed again. Most of the patients had visitors and they were curious, but not distressed. The woman in the next bed, though, was visibly upset. She held a tissue in her hand, but she didn’t use it for the tears that fell from her eyes, she just folded it and unfolded it, over and over, as I watched. I sat in the empty chair next to her bed and waited.

  After a few minutes, she looked at me.

  ‘I shouted at her,’ she said. ‘In the night, I shouted at her to shut up. Now she’s dead.’

  ‘You had no way of knowing that, though,’ I said.

  ‘She was making so much noise,’ said the woman. ‘Moaning and groaning.’

  I reached out for her hand, and the folding and unfolding stopped.

  ‘You wouldn’t shout at people, would you, if you knew they were going to die? I’m not sure how I’ll ever forgive myself.’

  When the porters arrive to remove a body, the curtains around the other cubicles are pulled to and the double doors to the bays are closed. The body is disappeared, out of sight, conjured away and through the unmarked door in the basement of the hospital, where it becomes absorbed into the rituals of the mortuary. It becomes a package for Rose Cottage. When the rest of the ward reappeared, shocked and curious, it felt as if those ninety-two years had never existed in the first place.

  We do not speak of death. In an age where we swagger at the thought of our own openness, death remains silent, hidden away behind curtains and codes and acronyms. For us as human beings, death reminds us of an inevitability; as doctors, it highlights the fallacy of a perceived weakness. We spend years learning how to mend people, and we line up our armoury of drugs and drips, and machinery, and we rage and fight and argue with death until the very end, as if it acts as some kind of a barometer of our usefulness. Unlike clinicians of years gone-by, society refuses to speak of the end of life as a natural progression, because to do so would threaten our own identity.

  Our stubbornness comes with a price. We have rehearsed conversations with patients about dying:

  In the event of a cardiac arrest, would you like us to attempt to resuscitate you?

  Yes, they cry, yes! YES! Of course they do. Anything else is unthinkable. The gaps in difficult conversations are filled with new treatments and drug trials, and hope. Death has become an adversary, dying has become a battleground. Patients make treatment choices based on these conversations, and our failure to speak openly and honestly means there is a danger of harming the very people we are trying to help. There are no soap opera deaths. Countless times have I chased around a hospital looking for a consultant to sign a Do Not Attempt Resuscitation form, because a patient has deteriorated, and there were no plans put in place. Death can be loud and messy and chaotic, and the nursing staff are, once again, left to pick up the pieces. Department of Health research tells us that 70 per cent of people say they feel comfortable talking about death, yet only a handful have discussed their wishes with family, and while most patients state they would prefer to die at home, due to the medicalisation of dying, very few manage to achieve this.

  If we are lucky, we will experience the quiet wisdom of the palliative care team. We will be allowed to die at home, or be given a side room. We will have had honest, open discussions where ‘end of life care’ is said with a sense of choice and empowerment, not an air of defeat. Until we learn how to have these conversations, until we stop talking in codes and acronyms, there will always be patients whose requests are never heard, and there will always be a package for Rose Cottage.

  Ninety-two years of life deserves more than the scraping of plates on a meal trolley behind a paper-thin curtain. It deserves more than a corner of a ward surrounded by strangers. It deserves a choice. It deserves some dignity. As medicine becomes more sophisticated, as drugs and treatments become more skilled at keeping us alive for longer, caring for our emotional health as well as our physical health is even more important. A good innings is so very much more than a number.

  Spaces

  Medical school helped me to diagnose and treat illnesses I would never get to see outside a textbook but failed to prepare me to deal with death. I was told, not even asked, to inform a family of the death of their husband and father following a heart attack, a man that only a moment earlier had been well, just because I was the most junior doctor in the department. I walked the small corridor and broke the news, unprepared, clumsily, badly, not helping those that cared to be cared for. This was my first death as a doctor.

  The consulta
nt

  In the third year of medical school, you are taken to one side and taught how to break bad news. This teaching involves important suggestions, such as:

  Ensure there is a box of tissues handy

  and

  Make sure you give the patient an opportunity to speak.

  There’s even a useful mnemonic, just in case you temporarily forget how to be a human being, because there is a mnemonic for everything in medicine, even death.

  SPIKES – the handy six-stage protocol for delivering bad news. Set-up, perception, invitation, knowledge, empathy, summary. Six boxes to tick, and we practise our conversations around these boxes, again and again, until we are able to fit everything neatly inside. We have workshops too, where we role-play and feel self-conscious, and try out our mnemonics on each other. Eventually, experienced actors are brought in to test out our ability to remember the protocols, but they do not, unfortunately, test out our ability to look death in the eye. The actors leave spaces in the conversation where we can carefully place our mnemonics, because the actors know all about them. The patients we will meet beyond the shelter of a medical school, however, do not.

  Towards the end of your medical training, you are expected to start ‘working’ shifts; that is, to follow a department, not only during medical school hours, but to witness how it operates around the clock. And so, just before finals, I found myself loitering around A&E at a time when I would normally be at home and tucked up in bed.

  On this particular night, it was absolutely pouring with rain. It was the kind of weather where people bluster in heroically, stamping their feet and letting out lots of loud gasps. Other than a man vomiting theatrically in one of the cubicles, the department was fairly peaceful, so I helped myself to a few chocolate Hobnobs and sat down with my workbook.

  I’d only been sitting there a few minutes when the telephone rang. Obviously, this isn’t unusual in an emergency department, but this was no ordinary telephone. This was the special telephone. The one that rings with an old-fashioned bell. And when that telephone rings, it means that something really bad has happened. In this case, the something-really-bad was an eighty-three-year-old lady called Jessie who was having a heart attack.

  When the special telephone rang, magical things started to happen. People appeared from nowhere and put on plastic aprons. They brought out lots of mysterious equipment and started writing everything down. If you ever want an example of good teamwork, the resuscitation room is an excellent place to start. Everything is done with breathtaking efficiency. After a few minutes, everyone had been given a role to play and the performance was ready to begin. They just had to wait for Jessie.

  When she arrived, it wasn’t with the crash and drama of an episode of Casualty. It was quietly and almost apologetically through the ambulance bay at the back of the hospital. One of the nurses was doing chest compressions, but she wasn’t riding side-saddle like in the movies, and there was no sign of George Clooney anywhere. They flew past me in one giant chain of human beings and vanished through the swinging doors of the resuscitation room. Then I noticed that behind the paramedics and the bags of saline and the red blankets and the chaos was Jessie’s husband. He was old and bewildered and wet from the rain. They asked him if he’d like to sit in the relatives’ room, but he was too upset. The kind of upset where you want to pace up and down. Half an hour ago, he’d probably been sitting with Jessie in their sitting room, watching the television and thinking about calling it a night. Now he was in a bright noisy hospital and his wife was lying on a trolley, covered in leads and blankets and surrounded by strangers. I’ve been that kind of upset before and the last thing you want to do is sit down with a nice cup of tea.

  They tried very hard with Jessie, but her eighty-three-year-old body had had enough and wanted to leave. I watched them work on her. I watched the drugs going in and the blood being taken out and I watched as they called time of death. I wondered if I would ever get used to seeing people die. Although it’s not the dying part that really upsets me; it’s the part afterwards that got to me every time.

  I knew that, very soon, they would be taking Jessie’s husband into one of the quiet rooms, where they would turn his life upside down with one sentence. He had stopped pacing and, when I left the Resus room, he was in the middle of the corridor, staring at the floor and looking for somewhere to be. As I watched him standing there, the rest of the world walking around him, I noticed something for the first time. Hung over his arm, slightly crumpled and with its belt trailing on the floor, lay Jessie’s navy blue raincoat.

  As a medical student, I had sat and listened many times as patients were told that their cancer was going to kill them. I have heard many consultants fire a warning shot (I’m sorry, Mrs Jones, but I have some bad news) and I have witnessed the breathtaking silence that follows these words, as we all wait for the patient to respond.

  There is no silence quite like it.

  When the patient finally speaks, it’s often to offer up a reason to be positive. They quote their friends and the internet and things they’ve seen in the newspapers. They tell you stories of people they’ve read about, or people who are related to people they know, or people someone once told them about. People who have defied the laws of medicine. Lastly, when all of these attempts at cheerfulness have floundered, they will give you their final fragment of optimism. The only one left.

  ‘They’re always making amazing new discoveries now though, aren’t they?’

  And then they will leave a pause. A gap in the conversation. A space between all the words where you are expected to place an offering of hope. Sometimes, though, there is no hope to be offered. Sometimes, there is nothing else to be said. The space remains empty and you listen to the sound it makes, as it swallows up everything else.

  Medicine is filled with spaces.

  Wards and clinics are built on spaces. Spaces in which to put expectation and possibility, optimism and anticipation. We wait in those spaces for test results, X-ray films, scan reports. We prescribe drugs and, as they swim around within a patient’s bloodstream, we hold our breath in the space between administration and response. Waiting rooms are crowded with spaces. In a consultation, a patient’s anxiety rests in a space the width of a table, as they search for an answer in a doctor’s eyes. On the wards, relatives crowd into a side room, looking for a whisper of something they can hold on to, and, in the space between them, in curtained light, hope waits alongside.

  As medical students on the wards, in many of our placements we were encouraged to follow a patient from admission to discharge, to take their history and to get to know them, to follow their diagnosis and treatment, and to write up and present our thoughts and learning when the patient is discharged. There is heavy competition to find a patient and many of the ‘best’ ones are snapped up early. The ideal candidate is interesting enough to fill a presentation, but not so interesting that the workload is increased by having to read up on rare and unusual conditions in case you are asked rare and unusual questions by the consultant in charge.

  In one of my rotations, I trawled the wards, looking for a patient to follow. I read through trolleys full of patient notes and scrolled through referral letters on computer screens. I scoured patient bays. I interrogated nurses. On hospital wards, there is a very high proportion of older people. Some 80 per cent of the patient list consisted of people over the age of seventy: those who had been admitted many weeks ago after a fall or with a chest infection – problems long since resolved – but who could no longer return to the life they had once led. They had turned a page. They couldn’t manage stairs or their garden path or their lives any more, and so they waited, in wards and bays all around the hospital, for a different beginning. I loved talking to them because their stories were ones that would eventually become silent and disappear forever, but they weren’t suitable for a case presentation. I began to wonder if I would ever stumble upon anyone, and I almost gave up, but on yet another circuit of A&E I final
ly found my patient, lying on a trolley in Majors. His name was Paul. He was thirty-eight.

  Paul had been sent there by his GP after presenting with a short history of weight loss and lack of appetite. Vague abdominal pain that reached into his back. A vague feeling of nausea. Doctors’ waiting rooms are often filled with the vague and the indefinite, the out of sorts and the ambiguous. Symptoms that can be the result of many different illnesses, some sinister and some untroubling, some that will disappear all by themselves and some that need urgent attention, and it’s the GP who has the unenviable task of sorting out the tigers from the pussycats. It wasn’t the vague abdominal pain and the vague nausea that made the GP suspect that this might be a tiger – it wasn’t even the weight loss or the tiredness, or the feeling that something ‘just wasn’t quite right’. It was the jaundice.

  Every medical student has a list of things to find on the wards. Checkboxes to tick. Clubbing and cyanosis, atrial fibrillation and ascites. Jaundice is also high on this list, and we stalk the hospital looking for examples, our pens poised over our workbooks, like medical birdwatchers.

  Do you think the patient in bed four has jaundice? we whisper to each other.

  We all walk past several times in covert manoeuvres before we dare mark a tick, not wanting to be fraudulent. We are unsure. Undecided.

  Until we see jaundice for real, for the first time, as I did that day in A&E, and we realise there is no mistaking it. No need to walk past a bed several times. No need for hesitancy or self-doubt. When you see jaundice like that, you know you can’t possibly be looking at anything else.

  I walked over. I loitered at the foot of the bed. Paul looked up and smiled, and his wife looked up and smiled. I introduced myself. I very quickly explained that I wasn’t a doctor, because I had learned early on that if you wear a stethoscope and you aren’t twenty-one, it pays to make it clear. People always look at your face, not your name badge, which is why Kate Granger’s #hellomynameis campaign, which reminds NHS staff of the importance of introducing yourself to a patient, is so vital. I told them I was desperately searching for a patient to present at the end of my rotation, and would they mind if I talked to them?