“How long have they got left to live?” This is a question I am asked at least once a week. There is no way I can give a completely accurate answer but I try my best to give an approximate time period. Months to years. Weeks to months. Days to weeks. Hours to days. These are the standard replies I give, for the weather forecast they have asked me for.
Over the years I have had a lot of practice. My educated best guesses have come closer thanks to lived experience. I am often wrong as there are too many things that need to be included in the considerations.
“Should I call the loved ones in?”
Better they come and visit too early, than too late. See them while they are still able to talk and interact.
I don’t know what will happen tomorrow, let alone next week.
I will try to give you as much warning as possible, but sometime I may be caught by surprise myself. The final deterioration may not announce its arrival. It might sneak up on everyone, including the person themselves.
I’ll keep on trying my best, but I don’t mind being wrong when it comes to prognostication.
Any medical history is incomplete if the social history is not assessed. An important part of the social history is occupational history. What line of work a person did can tell you a lot about them. What jobs they held and for how long can provide a clearer image of who the person is. It can indicate what level of education they have had. Also, it can provide clues as to how they have done financially. Where did they work, locally or overseas? How important was their job for them? What level of loss has occurred as they are no longer able to work? Is there any unfinished business? Is there anything that needs to be sorted out in relation to work? What has been important to them up until now? Was there a work-life balance or otherwise?
The above information gives you a better idea of the human being that is in front of you and their place in society and the world. What is the best way to communicate with them, and how can you discuss things in terms that they will be able to follow? Talking to an engineer is different to talking to a chef. Talking to someone who has devoted many years to home-schooling their children is different to the conversation you’d have with a truck driver. The conversations are aimed at finding clues about who the person actually is. What analogies would help improve understanding? What kind of language to use or what level of detail to share? What is important to them at this stage of their life? What do they still have to sort out? How can you best build rapport?
How can we connect with them? What do we need to know about them in order to take better care of them? What did they spend a big chunk of their adult life doing? Also what hobbies do they have and how passionate have they been in pursuing those activities. One human trying to get to know another human, trying to connect with them to help them out. Striving to make a connection.
Any medical history is incomplete if the social history is not assessed. An important part of the social history is occupational history. What line of work a person did can tell you a lot about them. What jobs they held and for how long can provide a clearer image of who the person is. It can indicate what level of education they have had. Also it can provide clues as to how they have done financially. Where did they work, locally or overseas? How important was their job for them. What level of loss has occurred as they are no longer able to work? Is there any unfinished business? Is there anything that needs to be sorted out in relation to work? What has been important to them up until now. Was there work-life balance or otherwise?
The above information gives you a better idea of the human being that is in front of you and their place in society and the world. What is the best way to communicate with them, how can you discuss things in terms that they will be able to follow. Talking to an engineer is different to talking to a chef. Talking to someone who has devoted many years to home-schooling their children is different to the conversation you’d have with a truck driver. The conversations are aimed at finding clues of who the person actually is. What analogies would help improve understanding. What kind of language or what level of detail to share? What is important to them at this stage of their life? What do they still have to sort out? How can you best build rapport?
How can we connect with them? What do we need to know about them in order to take better care of them? What did they spend a big chunk of their adult life doing? Also what hobbies do they have and how passionate have they been in pursuing those activities. One human trying to get to know another human, trying to connect with them to help them out. Striving to make a connection.
End-stage COPD (chronic obstructive pulmonary disease) due to lung damage from smoking had been his problem for the past decade. Lung tissue destroyed by toxic exposure leading to severe shortness of breath. He needed oxygen at all times, and could only at best mobilise short distances. Life had become a struggle, and just when he thought things couldn’t worsen, they did.
He was in really bad shape when he came in on Friday, he was only semi-conscious and could not respond to my questions. His wife and son, who were his main caregivers at home, looked exhausted. He looked terrible, blue lips and tongue, breathing rapidly, short, shallow breaths, with only a small amount of chest movement. I had not seen him so unwell before, which really concerned me.
Using all my clinical skills and experience, I really thought that he was dying, that he would die within the next hours. That he might last only days, and might never fully wake up again. I gently conveyed this news to the family. That I thought this might be the end of his life. They took it well, he had been unwell a long time, and had been close to death many times in the past.
I prepared his medication chart for end of life care. I wanted to cover the five common symptoms that occur at the end of life; pain, breathlessness, nausea, agitation/confusion, respiratory secretions. Anticipatory prescribing for a dying person is done, in order to cover the things that occur commonly during their last hours to days of life. Aiming for comfort more than anything else, we started him on syringe driver medications. This would mean a continuous infusion of symptom control medications to keep him calm and comfortable for whatever time was left. I left that Friday afternoon truly thinking that I would not see my patient alive when I returned after the weekend.
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