Saturday, 20 August 2011

Dying at home

The Doctor Sir Like Fildes 1887 Tate Gallery
Most people no longer witness the death of a relative at home. The Victorian scene so often described by Dickens, and still experienced in many homes throughout the 1920s, has faded from memory. Even modern GPs seldom care for patients thought the final stage of dying. The hospital and the hospice sharing the spoils.

I would say that to  make yourself available to the patient and her family, where a death is to be expected, is a worthy consideration. And with the advent of mobile phones, no longer is one housebound waiting for patients to call, or expecting one's spouse to man the home phone whilst the doctor drives around with a bleep.

I say this because a few months ago I gave my mobile phone number to the family of a patient of mine dying at home form advanced malignancy. I explained that they could call me any time of the night or day, but I made it clear that I might not be able to attend depending upon my circumstances. As it happened they called me about 3am on a night when I had moments earlier taken a call from my sister advising me that my mother had just been admitted as an emergency in the local hospital.

I visited my now deceased patient. Confirmed the death and spent a few brief sympathetic moments with the family. Just this week I received a touching note from them expressing their thanks. In this week's BMJ Iona Heath writes a typically thought provoking piece on consent for cardiopulmonaty resuscitation. Suggesting that opting in for resuscitation has much to be commended for it, rather than the current opting out-which leads to many awkward conversations between doctors, patients and their relatives. She discusses the place of 'do not attempt resuscitation (DNAR)' orders and the inappropriate behaviour which professionals engage in when attending an expected death. I was struck by this helpful paragraph,
When patients are dying at home, an unfortunate cascade effect can come into play. Relatives and friends are coping well and managing to provide just the kind of gentle care that most of us hope for in our dying days, but to people unfamiliar with death the last moments of life can be distressing and frightening. In this situation, all too often the carers will seek support by calling an ambulance, and this becomes ever more likely with the decreasing availability of a familiar primary care or palliative care professional out of hours(my emphasis). Once the ambulance is called, the paramedics are obliged to attempt resuscitation, however inappropriate. Guru and colleagues documented that 10% of cardiac arrest calls in Toronto were to patients with pre-existing terminal illness, and in 63% of these the relatives asked in vain for resuscitation not to be attempted.5 The authors conclude that the carers of terminally ill patients should be specifically advised not to call an ambulance and to be given information on other sources of emergency support. (Read the rest here)
Most GPs do  not care for many patients dying at home each year. Give the family your mobile number. It's just a tiny bit of traditional family practice that will mean so much to the grieving family in the months and years ahead. And will cement your relationship with them throughout your career-assuming you're not going to change practice every 5 minutes.


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