Dave Caesar: Patient’s last days should be important

IT’S Armistice Day, and a beautiful thing happened in the Royal Infirmary of ­Edinburgh Emergency Department.

At 11am, amidst all the usual hubbub – conversations between clinical staff and ­patients, equipment and stock being moved on creaky trolleys, family members coming and going with concerns over relatives – the nurse in charge for the department requested we observe a two-minute silence.

And we did, all of us. Staff, patients, family members, carers. You could hear a pin drop.

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It allowed such a unique window of reflection that, having thought about the ­indescribable horror of trench warfare and all the subsequent deaths and injuries, physical and mental, that our servicemen and women and their families have endured in securing our and others’ freedom, all I was left with was the thought that we should do this more often. If nothing else, it ­allows you to remember what is important in your life, and your patients.

Just before we observed our moment of silence, I was discussing a patient with one of our excellent foundation year doctors. She had just assessed Edith, and was coming to summarise her findings and ask me some advice about what we should do next for her.

Edith is 102 years old. She was alive when the First World War broke out, and still lives in her own home with help from carers four times a day. This in itself is quite an achievement, and on this day she had been found by her bed, having had some difficulty in operating the mechanics of raising and lowering her bed. It didn’t seem like she had injured herself, or was particularly different to her normal self. In fact, the carer that called for the ambulance and brought her in mentioned that this happened quite frequently to Edith, and that often she just pulled her covers off the bed and slept on the floor.

“She says she feels fine and is really keen to go home,” my junior colleague tells me.

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So we have an 102-year-old who has an issue with her bed and is now in the ED. Having spilt a fair amount of sweat and tears building my son’s cot (which my daughter is now trying to destroy) and then bed, I can categorically say that this is not an area of expertise for me.

This is also not that uncommon a scenario – a frail ­patient has a turn of events that may or may not have a medical cause or consequence, and they find themselves in the Emergency Department. At this point, there is probably a 50 per cent chance they will then be admitted to hospital, as the avenues for returning them to their home are so difficult to navigate, and do not respond with the speed required to service our four-hour Emergency Access Standard. It is one of the greatest frustrations of working in our specialty.

However, if ever we had a chance to help Edith get home, this is it. It is 11am on a weekday, she is uninjured, and she wants to go home. She has an existing comprehensive care package, and seemingly no medical cause for a fall. All the stars seem aligned. If only all our elderly patients arrived in this way!

Our foundation doctor goes on: “But, she does seem a bit dehydrated, and I wonder whether her bladder is a bit distended. I was thinking of scanning her and then maybe catheterising her, and then . . .”

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I have cut her off mid-sentence. This is where our role as doctors needs so much work. We go looking for things we can “fix”, interventions we can do to make ­patients “better”. She was also planning on admitting Edith “to be safe”.

If there is one place Edith should avoid at all costs, it is an acute hospital. We need to change our perspective from “what can I do to this patient?” back to “what matters to the patient”?

Edith wants to be at home. That should be our prime mission. Not only is that the place where she can remain as independent as she can be, it will also avoid all the potential interventions and dependencies that come with being in a hospital. It means she will remain orientated, not confused with potential to fall in hospital. It will keep her in better condition than we can with all our medicines at our disposal (often more perilous than helpful).

And at 102, there is a high chance she will die soon. This inevitability shouldn’t be shirked, but planned for. I, for one, would not want to die in a hospital bed, but in my own place with my family around me. We often delude ourselves as doctors and citizens that this is somehow avoidable, and worth throwing everything at. It isn’t, but unlike those millions that died in the world wars, we will often have the luxury of time to consider what will be important to us as we approach the end and plan for it. It also struck me that, with all the publicity around the Tower of London poppies, we don’t seem to have a problem talking and thinking about other people’s deaths. Maybe we should give ours some thought, too.

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