Signs of Impending Death

The title of this post may sound too medically based, since it seems to focus more on just the signs of death. But having a palliative care doctor assign me this topic to present at our next palliative ward round, I figured it would make for an interesting read.

I was 25 when I witnessed a patient who passed away in front of me. I was still an intern then, and was asked to see the patient in front of many family members. The patient had agonal breathing – periods of deep sighing breathing, followed by long pauses of silence. After a few minutes, the patient stopped breathing at all. Being fairly uncomfortable in such a situation, all I could do at the time was examine the patient, and inform the family that their loved one has passed away.

That was some 3 years ago. I have assessed many more deceased patients since then.

Having used an ebook database, I find out that some of the signs of impending death include:

  • Decreasing cardiac output: increased heart rate, hypotension, cyanosis, mottling, livedo reticularis
  • Renal failure: oliguria, anuria
  • Neurologic dysfunction: decreased level of consciousness, terminal delirium, hypo/hyperactivity
  • Reduced oral intake.

During our palliative ward round, we see a patient who seems to have signs of dying. It was an elderly man who presented due to what appears to be pneumonia. He was drifting in and out of consciousness. He had reduced oral intake. And he looked pale. The man ended up succumbing to his pneumonia, despite IV antibiotics we were giving. Realistically, he didn’t improve after 3 – 4 days of IV antibiotics, and so we had to explain to the 2 daughters that he wasn’t likely to pull through.

I remembered this man from a few weeks back. He was up and talking back then, cracking a few jokes even. I found it hard to believe that he was so well just a few weeks ago.

From what I’ve seen, disease does not discriminate against people. It attacks people of any age.

Breaking Bad News

Having been in oncology/palliative for the past couple of weeks, giving bad news was bound to happen some time.

In medical school, it was always about SPIKES. That’s:

S – Setting – Make sure you’re in the right setting for such a discussion where there is minimal interruption, and plenty of time available for discussion.

P-Perception – Gauge an understanding of what the patient knows to date about their condition so that you know how much you need to tell them.

I-Invitation – This for me seems to be the hardest to get my head around. But the invitation is the time where you essentially ask the patient how much information they want eg “with your recent CT scan, would you like me to tell you everything about it even including the not so nice information, or would you like me to skim through the results and go onto treatment options?”

K-Knowledge – This is essentially the delivery of the detailed information to the patient.

E-Empathy/emotions – Be empathetic and understanding. Essentially, if a patient is crying, offer some tissues. If they look stunned, and shocked, give them some time to process the information.

S-Summary – This is about repetition of the information given beforehand. It’s likely many patients have stopped absorbing information after the initial bad news. Repetition allows them to get the information again.

 

Having been the radiation oncology resident (in addition to the palliative/oncology resident as well – where’s my triple pay?), I was tasked into reviewing radiation oncology patients. There had been this one lady in her 70’s, who had recurrence of vaginal vault cancer, with previous groin lymph node removals for her cancer. She was undergoing radiation therapy with potential curative intent initially.

When the patient was initially admitted under radiation oncology, palliative services were provided, given the patient had pain issues on mobilizing. What didn’t help was this patient had a BMI of 53.

On the palliative ward round, the patient had advised of left hip pain as well. An examination revealed extreme tenderness on passive motion. So a CT hip scan was ordered. And then a CT chest and abdomen were ordered as well (let’s scan everything as well while we’re at it! ). The CT results weren’t good. The left hip pain – completely explained by a pathological fracture at the left hip – specifically the labrum of the hip. And the abdomen – showed that there was a right adrenal gland metastases.

With that CT scan, the patient had gone from “potentially curable” to “incurable”. Of course, being the resident to first see these results, I had the unfortunate job of breaking such bad news. The husband and the patient were lovely people, and were very friendly. Being Italian may have had something to do with it.

So, after reading and re-reading the report numerous times, I prepared to walk over to tell them the results. I was scared though. Scared that I’d break the news terribly. Scared that perhaps the husband might get angry and start shouting at me.

It wasn’t as bad as I had thought, and the patient and husband were very understanding people. On reflection, I don’t think I did invitation in the SPIKES protocol too well. But then, it seems like a really awkward way to ask a patient “if they want to know everything, or only a little of something”. I ended up just telling her “unfortunately, the scan appears to have showed that your cancer has spread to the left hip region, and to the glands sitting above the kidney”. I later explained that given the spread, the prognosis is not too good now compared to her previous well localized cancer.

The husband later ended up telling me how he appreciated my honesty and the straightforwardness of telling them. “You’re not like the last doctors that kept beating around the bush”. Well, I suppose the previous doctors had more uncertainty in breaking the news back then compared to me who had clear results from the scan.

On reflection, I think that it was a very important learning experience. I’m pretty sure as a GP next year, I’ll have lots more of these situations.

GP Placements

Having just had about 4 weeks of annual leave, I wish I could say that I had a pleasant holiday. However, aside from going to a foreign country that has a great big firewall *Cough* *China*, I have to say that it felt incredibly busy, almost as if I was working.

For starters, on return from my trip from China, I would have to sit a Chinese written exam. I suppose being in China helped somewhat with this by being exposed to the language, but what we get tested on is entirely based off a textbook, which I had to carry around and study in my spare time while at the hotel.

The next most annoying thing, was that I had somehow organized an oral assessment task for my paediatrics diploma for the 3rd of June, also a few days after I returned back home from China. So I ended up studying for that as well, staying up late at night in the hotel to study. It was only after 2 weeks into my trip to china that my assessor advised me that she couldn’t make the 3rd of June, so I was able to push it back to the 17th of June.

Another thing (the tasks just keep piling!), was that I had to do some research into the application process for next year’s GP practice intake. This involved lots of boring reading online about the steps needed, the rules and regulations etc… And I also needed to update my CV, and write a letter of application, not to mention thinking about interview questions and how to best answer them. So this too involved long late nights of work in the hotel as well.

So my holiday kind of went like this….

  1. Arrive in Guangzhou, China all exhausted
  2. Find hotel and place to stay
  3. Study
  4. Go to Guilin and Qingdao by train and plane respectively
  5. Study on the train and on the plane while going to destinations
  6. Start stressing out as date of chinese exam, paediatrics assessment task and GP application date starts approaching
  7. Big sigh of relief once assessor postpones oral assessment task
  8. Continue to study in hotel till late night anyway despite the above

After that, I came back home, having happy memories of my time spent studying in the hotels…….

Well, I still need to work on my applications for GP, which I shall hopefully submit tomorrow.

Looking at the World

Since having a medical education, it has made me look at people in ways that I never used to look at them. I’m more observant of people around me.

In medical school, the crucial thing we were taught, was to use our eyes. In our clinical examination classes, we were taught that a general order of examination of the patient was: observation, palpation, percussion, auscultation. Note how observation comes first and foremost before you touch them, and before you use your stethoscope.

And so we’re told that you can glimpse a lot of information about your patient just from watching them. A person who limps into your practice may indicate something like pain from the knee or hip (maybe from osteoarthritis), and an infant who is brought in in the mother’s arms with reduced responsiveness and alertness is probably quite sick.

When you’re observing people all the time, it only becomes natural that you apply it in public. In general, the major thing I glean from seeing people are whether they are well or sick. Then little other subtle things I may observe – things like gait, scars present (may indicate things like past knee replacements), and just other things in general like if they’re pale, have rashes or so.

In turn, I guess being able to apply it in public means that I’m constantly using the skill of observation, and hopefully it will aid in my further career development.

Paediatrics – It Made Me Sick

I remember having done paediatrics as a student and as an intern. Both times, I got sick. Probably for only about a week or so, but then I got better, so I could enjoy the rest of the rotation.

I’ve been doing paediatrics now for about 6 weeks. And I hate it. Well, that’s probably not entirely true. I like managing and diagnosing paediatric conditions, but I hate the germs and bugs that comes with the patient group.

Every second or third child is a febrile, coughing, runny nosed kid. With such a high exposure rate of flu viruses and bacterial infections, it was only a matter of time before I became sick. And sick I became. In fact, for a total of 3 weeks! Yes 3 miserable weeks of suffering!

Thinking back to it, the first time I got sick, I had to cancel dinner plans with a friend. I started feeling better over the next few days, but had to do a 4 day stretch of nights. And on the last night shift… I got a sore throat. So I get sick some more, with some laryngitis, hoarse voice and the like. Just as it’s improving …. I get unilateral throat soreness. I don’t think much of it, thinking it’s viral. But over the next 2 days, I become febrile, I get chills, I have extremely painful lymph nodes, and I think I can see some exudate in the back of my throat.

I only just started some antibiotics today, and it’s already helping a bit. My throat doesn’t feel so sore anymore. I just hope I don’t spike fevers again tonight.

I must be extremely unlucky with 3 successive episodes of throat infections. I think I’ll be extremely glad to leave paediatrics behind and to leave a miserable few weeks of illness behind as well.

Departure

Mid January, and I was out of a regional hospital (which served population of 65,000 people), and into a metropolitan hospital. To say I was excited was definitely an understatement.

Having spent 2 years at the regional hospital, I felt I wasn’t being challenged enough. In a way, things became too routine. Education was still awful for second year residents. And beside the work aspects, I was starting to tire of the constant long drives back to my parents place at the city centre.

I must say, having a last rotation as relief, it put me everywhere and anywhere in the hospital. Medicine was absolutely the worst, in that they were so short staffed, that even though I told them weeks in advance that I could not work Friday, Saturday or Sunday on the last week of work, they still put me those days, and yet worse, put me on for night shift. I had to complain to them that it wasn’t possible before they did something about it, and told me not to worry. Yet, 4-5 days before I’m about to leave, they suddenly tell me that I will need to at least work Friday night shift. So, thinking I’ll help the hospital out one last time, I agree. This is on the condition that I have a 2 days to stay, since I would have handed my keys over to my land agent, and reduced hour from 8:30 pm to 5:30 am (since I needed to rest enough to drive back to the city region).

The night of work went much better than expected. I only got 2 calls to see 2 patients, so got a good 3-4 hours of sleep.

After work, I went to the hospital accommodation, and got in an extra 2-3 hours of sleep, and then the long one way drive back home to my parents place.

So it’s been about 10 days since I’ve been back home. Surprisingly, I don’t miss the town I left as much as I thought I would. I’m guessing it’s because of my bachelor life there, and the fact that there wasn’t really anything too personal for me to miss there. I always thought that being single was awesome in that regard – they won’t feel the pain of missing something whenever they live a town/city.

Anyway, I feel that a chapter has finished, and a new chapter starting – a life in the busy city again, where I’ll actually get to work. And perhaps I may find someone I like here – there’s definitely much more opportunities.

I think this year is going to be busy, but busy in a good way.