do not go gentle into that good night

"and you, my father, there on the sad height,
curse, bless me now with your fierce tears, i pray.
do not go gentle into that good night.
rage, rage against the dying of the light."
- dylan thomas

the dying process is often associated with physical and psychological suffering, and in palliative care, we try to alleviate this and achieve a peaceful, dignified death for our patients. we often console our patients and their families with this promise and sometimes this helps them to move on from the shock and hopelessness of a terminal diagnosis.

however, despite our best efforts, sometimes we fail. although total failure in the form of a screaming patient surrounded by crying family is thankfully a rare occurrence, often the medications we use to treat symptoms compromises our patients' mental faculties. they spend more and more time sleeping. and when they are awake, they find themselves in the grey zone: unable to concentrate, their thoughts wander as their minds slip back into the haze, their senses dulled, their humour muted. they become the hollow men, a shell of the people they once were. it's a horrible state of being.

i don't know how i would like to go. i certainly don't have the right to tell my patients how they should go. but what i do know is that, even though we might like our dying to be peaceful and dignified, sometimes it's noisy and messy, filled with gasps and groans. and despite all that we are trying to achieve in palliative care, sometimes, a person's struggle against death can feel so overwhelmingly noble, human and right.

"this is the way the world ends

this is the way the world ends

this is the way the world ends

not with a bang but a whimper."

- t. s. eliot

politics

being a registrar involves managing people:

- its leading and teaching the residents, interns and medical students.

- its liaising with all of the consultants, working around their varied styles.

- its coordinating care with the other medical teams, nurses, allied health, hospital administration - knowing when to compromise and when to stand firm.

- its also about looking after myself - recognising when im tired, hungry or close to losing my temper, then stepping back from the brink.

all of these tasks are crucial to being a good registrar. but, for me, i would still like to believe they're secondary to caring for my patients and their families. now may be ive got that wrong. but im yet to find out the hard way.

my patient is dying. she has a prognosis of days. all of her energy and will is directed towards a significant family event that has been looming for months. afterwards, i would not be surprised if she fades quickly to nothing. i have seen it before. many times.

she has not been the easiest patient to look after. at times, she refuses our recommendations. she has her own reasons for these choices, and although i do not agree with them, they are not random or irrational, so i respect them. patient autonomy is a cornerstone of medical ethics that i believe in and guides my medical practice.

however, another key tenet of medical ethics is that of resource allocation. the hospital is full. patients are backed up out the doors of the emergency department. there is a bed at the palliative care unit, where my patients care needs would be better met. but she has consistently refused to go back there after a previous bad experience, despite our attempts to overcome this. she is taking up an acute bed and other patients' care are being compromised as a result of this. (of course, the other patients' care also also being compromised as as result of bad planning by the hospital administrators - but naturally this is not something they would consider.) the hospital administrators tell me that i must send her to the palliative care unit, against her wishes, or discharge her home, where her care needs could not possibly be met.

naturally, i refuse. patient autonomy trumps resource allocation. so the drama escalates. i am called away from patient care by various urgent pages, phone calls and meetings. my suggestions for alternatives are ignored. more patient care is compromised but the hospital administrators do not see this. they want her out. everything else must wait.

i give in and try again. i shake her awake from her restless sleep. she is drowsy and drifts in and out of the conversation. i make promises i don't know if i can keep. she seems to understand, and finally nods yes.

i leave feeling like ive done a bad thing.

reflection

we had a session on reflective writing the other day, as part of our fortnightly palliative medicine training sessions. we were each given a fancy notebook with hard covers (!) and then told to write whatever we wanted for half an hour.

it was hard to get started. knowing that i would probably have to read what i've written in front of the other trainees in the group and our facilitator (a palliative care consultant) didn't help. it took me a couple of minutes just to pick a topic that wouldn't invoke too many emotions. i guess i didn't want others to judge me. for all the posturing i do ("i don't care what other people think," i tell myself...) i guess scratch the surface and i'm really still the awkward self-conscious fifteen year-old.

the other thing that made it hard, i thought, was that i "never" do any reflective writing. but then i realised that that hadn't always been the case. this blog consists mainly of reflective writing. listening to what the other people in my group wrote, then to myself reading the dry uninspiring prose i'd struggled to put together, i felt a little sad that i'd let it go for so long...

well, maybe it's not too late to pick it up again.