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A cautionary tale

Pneumonia is sometimes referred to as “the old man’s friend”. The helping hand at the end of a long life, guiding many a tired, aged traveller on their final journey to the grave. Allowing it to take a loved one is sometimes a blessing. Fighting it can sometimes be a curse.

An elderly female patient was admitted to the medical ward with pneumonia. She was in a single room. Her daughter and son by her side. The steady rise and fall of her chest was like a metronome beating out the rhythm of her life. Tiny tears slipped from the corners of her closed eyes and slid down her pale, wrinkled cheeks. Eyes that could not see the slipping away of her life force. Ears that could not hear the pain in her daughters wavering voice. Arms that did not feel the touch of her child’s warm embrace. Unconscious – her brain barely active. Her body, starved of nutrients, was slipping away. At times she groaned, almost as if in pain.

Death was in the air. You could smell it. You could feel it. You could sense it like a cold thin trickle of water running down from your neck to the small of your back. It felt like a cold heavy blanket hanging over the space of the small hospital room. Suffocating.

A drip was running. Antibiotics were being given. Oxygen via a mask. Her daughter was angry. It was all taking too long. Her mother was fighting. Fighting for her life. The stress of the battle was sometimes all too much for her daughter. She would berate the staff for perceived wrongs - action or inaction. She stayed at her mother’s side day and night waiting for a change.

Slowly but surely that change did come. The doctors and nurses fought for the mother’s life when she could not fight herself. She slowly improved. She beat the pneumonia and left hospital alive and well – albeit a little frail by the end of her skirmish with the scythe carrying spectre of death.

Made you feel a bit warm and fuzzy didn’t it. The thought of this mother-daughter pair pulling through against terrible odds. The medical team defeating the infection within. Medical science prevailing. However, all was not as it seemed.

The mother had been unconscious because the daughter had insisted on her having a Morphine and Valium infusion when was first admitted. The mother had been dehydrated because the daughter had refused intravenous fluids. The mother was in pain because the daughter had been obstructive towards the nurses to provide basic nursing care including pressure area care. The mother went backwards at one point because the daughter had turned off her oxygen.

I was the intern on for the medical ward that fateful weekend. I had been out of Med School less than a year. I was confronted with this mess on a Saturday morning when all I wanted to do was quickly tie up some loose ends, write up some drug charts and retreat to the cafeteria and have a cup of coffee and read the paper. I stood there, slack jawed, in that tiny little room and listened to the daughter say “she’s taking forever to die”.

I stopped the Morphine and Valium infusion.

I gave her intravenous fluids.

I made sure the physios saw her.

I made it abundantly clear that this patient needed acute medical care and not the palliative care that the daughter had sought when she was first admitted. She had emphysema and a chest infection.

I was so concerned about the manipulative and abusive actions of the daughter that I wrote a two page letter to the medical superintendent of the hospital where this all happened. I still look back on this incident and wonder just how she managed to talk the admitting medical team into putting up the Morphine and Valium infusion.

You COULD say that she was uninformed and confused and thought she was caring for her mother by attempting to take this course of action. That might be an understandable way of allowing your mind to make sense of this chaos until you found out that she was in fact a registered nurse working in that hospital. With that piece of information, you will get a tiny hint of the extent to which my mind was blown when confronted with this scene.

So why would I write this piece?

By writing it have I managed to expunge the distress that I still carry with me regarding this incident – no.

I wrote it because the story came back to the forefront of my memory when the Victorian government recently had its lengthy debate over assisted dying. In the end it passed although there will be many modifications no doubt before the practicalities of this legislation are completed.

Call it assisted dying or euthanasia. Call it whatever you want but it is essentially a system that will give patients and families a process by which a patient can end their suffering. I concede that there are some people who will not have their physical or mental pain palliated adequately even in the very best of hands. This number will be small. I agree that for that small number of men and women and their families, assisted dying would be a blessing. An opportunity for them to say their goodbyes and to leave behind their anguish. Some data from overseas indicate that even having this option and not necessarily using it, is enough to alleviate distress.

I have no idea about the legal necessities, the pharmacological practicalities or the diseases of the body and mind that might qualify someone to be considered for such a program. Likewise, I have no desire to be involved in any discussion to formulate plans for such a program. However, I would hope that my cautionary tale might allow you to take a step back, pause and consider that the purpose of such a system is to alleviate the suffering of the patient and no one else.

By all means bring in legalised assisted dying. We put down dogs for much less than the torment that some patients go through. The laws discussed in the Victorian parliament seem to be reasonable and the opening point covers most of what I have talked about – “Only the patient who wants assistance to die can ask for it”. However, I think we need to be ever mindful of the possibility that individuals can sometimes even unintentionally coerce the thought processes of their ailing family members. Over the course of almost 25 years of doctoring I have seen all sorts of people take advantage of each other time and time again. Don’t ever underestimate the lure of social, psychological, monetary, or property gain in bringing out the best and worse in people. It is, after all, (in)

human nature.

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