Further Confessions of a GP

We live in a time where drugs and technology allow doctors to cheat nature and keep patients alive for longer and longer. This is a fantastic achievement of modern science and every day I speak to happy, healthy people who would be dead without our medical input. This advancement does, however, have a cost. As I write this, Nelson Mandela is still alive in an intensive care unit in South Africa. The television cameras have been kept away, but any medic can imagine what sort of life someone in his situation would be living. He is likely to be asleep much of the time with most of his waking hours spent devoted to taking medications either orally or directly into his veins. The needles and blood tests will be constant, with the desperate attempts by the medics to keep his vital organs functioning. Food would be at best puréed and at worst fed through a tube. Toileting would be via a catheter and a nappy. It seems so sad that such a great man could be reduced to this.

When we doctors talk among ourselves we often promise that we won’t allow our own lives to be kept artificially prolonged in such a way. When machines and medication can keep your heart beating while nearly every other bodily faculty is failing, surely it is time for doctors to stop dragging out any last semblance of existence and let nature take its course?

As medics, our constant exposure to death and dying must affect us, and perhaps force us to consider our own mortality more intently. Personally, I still fear death, but I don’t dread it anywhere near as much as I fear being kept artificially alive in a state that offers constant pain and suffering. In his essay ‘How Doctors Choose to Die’, Ken Murray talks about his doctor friend who was found to have pancreatic cancer. Understanding the real consequences of this, his friend declined all the surgery, chemotherapy and radiotherapy that was offered, and instead chose to spend his last months dying peacefully at home with his family around him. As a doctor he had seen enough during his career to be able to make an informed choice about how he wanted his own life to end. If he hadn’t been a doctor, he may well have lived a little longer, but equally suffered a whole lot more.

But if doctors routinely choose to reject life-prolonging treatments for themselves, why do they often push so hard to keep their patients artificially alive?

There was a bad joke that went around medical school: why do coffins have the lid nailed on?

Answer: to keep the oncologists out.

As doctors, it can feel like stopping treatment is an admission of failure. We do often maintain treatment for too long, and definitely need to get better at stepping back and saying enough is enough. However, although we know that letting go is in the best interests of our patient, sometimes we fear that by withholding treatment we will be criticised and accused of callous laziness.

The Liverpool Care Pathway is a system that was set up to allow patients with terminal illness to die peacefully and with dignity. However, this protocol for allowing a natural death was picked up by many parts of the media as being cruel and barbaric. Grieving relatives accused doctors of allowing their nearest and dearest to die prematurely. Scared relatives requested that their dying relatives weren’t put on this so-called ‘death’ pathway, and as a result many people will have died after enduring more suffering than they needed to.

Despite all the uproar about the Liverpool Care Pathway, I always find it odd that its strongest critics never asked whether doctors would ever allow themselves or their loved ones to be put on it. As doctors, why aren’t we asked more often what treatments we would and wouldn’t give to ourselves or our own families? When I chose a boiler for my house, I asked the plumber which type he had at home. When I’m choosing dessert in a restaurant, I ask the waitress which one she likes best. There is nothing like a bit of inside knowledge when making a tough decision – and they don’t get much bigger than decisions about pudding!

Doctors make mistakes and get things wrong all the time, but we’re not, as large segments of society seem to feel, part of some sort of big evil conspiracy. For example, wasn’t it telling that throughout the whole MMR furore, I never met a single doctor who didn’t give the MMR vaccine to their own child? In the same vein, I don’t know any doctors or nurses who wouldn’t allow themselves to die on the Liverpool Care Pathway.