Understanding Mortality

As one approaches middle age, we start to question our mortality. Physiologically, like a well used car the bolts start to loosen, the tyres start to wear and the engine begins to sputter.

Like a well oiled machine that has been regularly serviced, used only the best oil and petrol and been driven carefully through the years, life can nevertheless be unpredictable. The best cared for car could be damaged by forces of nature, accidental damage or normal wear and tear. Similarly our bodies, with the best intentions are prone to forces beyond our control - slips and falls, accidents and general wear and tear.

Physiology dictates that with the years comes the strains on the system and normal wear and tear. Atul Gawande in his book "Being Mortal" provides some interesting insights into the human body and the impact of longevity. He recounts an experience when he sat in a consultation with a Geriatrician. The over 80yr old patient had numerous medical problems with the poly pharmacy that attends such diagnoses. The geriatrician however, focussed on the patients wellbeing and how they were managing activities of daily living. He took time to listen to how the patient was coping and then discussed a plan with the patient that would support them retaining their independence safely. It highlighted the importance of treating the patients and what was important to them and not just the disease that had hijacked their body. They want to continue loving as near normal as they can and the clinician should rather focus on achieving that instead of focusing only on their medication or the next investigation or test.

During a recent telephone triage shift, it was almost midnight and one of our regular callers was on the list, the son having called about 4 times that day. There was a plan of care, yet, this person called 4-6 times every night. The son picked up the phone when I called and instantly became defensive. I made a decision to try and listen to what was really the problem. It turned out that the son felt frustrated and helpless as they felt unable to help their dying parent. We discussed the importance of him looking after his own mental and physical health, seeing his GP and doing simple things such as having conversations with this parent instead of looking externally to express their grief. On other occasions patients have thanked me just for listening instead of 'trying to cure'.

At a recent conference, one of our lecturers Dr Balu Pitchiah talked about negotiating consultations. The most maligned is the 10minute appointment, which as a nurse practitioner I see how unreasonable it is but as a manager I understand this utilitarian approach. The Hippocratic oath required new physicians to swear to uphold a number of ethical standards as been glamourised and adapted over the years to suit the values of different cultures. It binds the clinicians responsibilities to his patient as that similar to a family member. This has evolved over the years to the healthcare professional often burdening themselves with this great sense of responsibility to cure and save or take on the problems of their patients.

Dr Pitchiah further explored resilience in healthcare professionals when trying to meet the demands of a growing population with evolving health needs and a system of rules, policies and guidelines that serve to keep the patient safe but brings with it unreasonable milestones. He advises that the clinician aim to negotiate a partnership with the patient. The ten minute consultation is an opportunity to set small achievable milestones with an equal partnership between the practitioner and the patient where each have responsibilities and tasks. This should be followed by appointments with clear goals to be achieved on both sides. This is more realistic and achievable with a greater chance of reward than a clinician taking on the 'woes of the world'.

I once read an interesting saying which I quoted within my Masters thesis on Patient Refusal of Lifesaving treatment.

" The role of the physician is to hold the patients hand while the disease takes it course".


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