Thursday, 28 January 2010

Lynn's story

On the 3rd December 2008, Lynn Gilderdale persuaded her mother to help her to die. She had been suffering from a severe form of ME since her teens, and at 31 she was tired of living her life confined to her bed, unable to speak or feed herself. She wanted a way out. A 'Do not resuscitate' order lay in her medical notes, her 'Living Will' alongside it, but to actually end her life, she needed help. I cannot imagine how painful it must have been for her mother to have been a part of this, and how terrifying. When the syringes of morphine didn't work Kay Gilderdale tried crushing anti-depressants and sleeping pills and passing them down Lynn's nasogastric tube. The deed still not done she added further morphine injections along with syringes full of air with the aim of blocking the blood supply to her lungs. It took 28 hours for Lynn to die.

This tragic story has finally been put to rest this week, with a jury clearing Kay Gilderdale of attempted murder. But it should never have gone to court. The real crime was to put a grieving mother through this extended ordeal for a prosecution which would have served no one. But there is another reason why I believe that this trial has been harmful, and that is because it has suggested to us that what Kay Gilderdale did was right.

Please don't get me wrong, it's clear that given the terrible circumstances that she found herself in, what Kay did was selfless, compassionate and brave. But are we truly to believe that it was right?

If you believe that it was, then what you are calling for is a change to UK law to legalise assisted suicide, or euthanasia. You must then consider the barrage of troublesome questions that this would raise. What if in a future case the 'assistant' had something to gain from the death? What of the pressure it could impose on those who are terrified that they have become a burden on family and friends? Where and how do you draw the line between what is acceptable and what is not?

If on the other hand you believe that what Mrs Gilderdale did was wrong, then you must maintain that it is preferable for someone like Lynn, with unbearable suffering, to struggle on. That it is reasonable to deny the help that she so desperately craved.

The truth is that it's disconcertingly hard to know where to stand on this. As a doctor I would never want to be involved in ending someone's life prematurely, yet nor would I want to be responsible for extending suffering. What I do believe is that we should not be encouraging people to take these decisions into their own hands. What took place in December 2008 would have been distressing and frightening for both mother and daughter and must not be seen as a satisfactory course of events.

So where do we go from here? Despite recent guidance from the director of public prosecutions, the legalities of assisted suicide remain unhelpfully vague and open to interpretation. Even so, I can't help thinking that new legislation is unlikely to be the answer here, in a field where each case will vary enormously and therefore should be looked at individually.

We do have a duty to help and support those who can bear life no longer, but whether this should be extended to assisting in ending life remains an enormous ethical question. The current situation however, where families are being forced into making these decisions in isolation and secrecy, not knowing whether criminal charges may follow, seems less than ideal.

Thursday, 21 January 2010


If there's one thing that I dislike about being a GP in the NHS, it's the terrible ten minute appointment slots. Let me take you through a typical morning to show you why:

8.30am - Patient 1 arrives

8.40am - Patient 1 leaves (well done me I think, an impressive start)

8.43am - Patient 2 arrives (he doesn't think he's late, I do)

8.50am - Patient 3 arrives

8.55am - Patient 2 leaves. Patient 3 enters and promptly bursts into tears.

9.00am - Patient 4 arrives

9.10am - Patient 5 arrives

9.20am - Patient 6 arrives

9.30am - Patient 7 arrives. I'm still with Patient 3. Very subtly (years of practice) I manage to flick to my computer's control screen. I see the word "waiting" repeated again and again down the morning list. I panic. I manage to lose Patient 3. But it's too late. I know that I am now destined to spend the rest of the morning frantically trying to catch up on time at the expense of listening to my patients. The day will pass in a frenzy of irritated patients, inadequate consultations and an increasingly stressed me.

I suppose to be fair, there are a few things that can be done in 10 minutes. Dealing with coughs and colds, toenail infections, diagnosing an ear full of wax, boiling an egg, having a shower, feeding the dog (I hasten to add that not all of these are recommended work time activities). There are however, many things that can't. Managing depression, admitting a patient to hospital, dealing with a new diagnosis of diabetes. Oh yes, and of course the; "Well there are a few things actually doctor - I've made a list so I wouldn't forget them". Groan.

Thankfully the BMA have recently acknowledged this problem, detailing the need to lengthen GP appointments in their pre-election manifesto. Unfortunately however they have also admitted that this can only be 'an aspiration' since it would require many more doctors which is clearly unrealistic in the current climate. More groans.

I however have been lucky. The practice I have now joined does offer 15 minute appointments and whilst an extra 5 minutes may not seem like a lot, it has revolutionised my working life. I have started to enjoy my job again and I feel that I can do it properly now. I am happier and my patients are happier. I have more time to listen, time for health education, time even perhaps just to chat. We of course are fortunate that we are a small enough practice to do this and still be able to offer enough appointments to meet our targets, the majority can't. But having seen it work and seen the difference it makes, I will be championing the idea that in the case of appointment times, we really do need quantity to achieve quality.

Thursday, 14 January 2010

Let them eat cake

Something happened to me this week that has changed my perspective on what makes my job worthwhile. It has proved to be a momentous event, a milestone in my career.

Someone brought me a cake.
You may not immediately understand the significance of this, but you see it wasn't just any cake. It was a chocolate cake, it was made for one (sharing not an option) and it came in its own pretty little box so that I could take it away, without fear of spoiling, and devour it in the comfort of my own home. But there's even more to it than that. It came from a patient who I do not know particularly well, not as a christmas present and not for a birthday, but just because. It was delicious, but more than that, it made me feel valued and that made me feel good.

I remember an incident a few years ago at the end of a long, busy night shift on a general medical ward. There's a particular sensation that you get at the end of a night shift, when the daylight breaks and it is time to go home. You feel shattered, disorientated, a little dizzy and usually pretty nauseated. So there I was, feeling shattered, disorientated, a little dizzy and pretty nauseated, quietly making my way in the lift down to the ground floor and the way out. I had planned to pop into the ward on my way home to check one last thing but when the doors opened on level 3 I could not face it and stayed where I was. There were two middle aged patients in the lift with me (no doubt on their way for a cigarette); "Aren't you going to get out?" they interrogated accusingly - they must have seen me press the button for that floor. "No sorry, I've changed my mind" I replied. They glared at me and under her breath one of them muttered, "urgh, doctors".
I remember wondering why on earth I did this job.

But now it's clear. For me, job satisfaction is not just about helping people, seeing people get better or making a brilliant diagnosis (which is lucky as this doesn't happen terribly often). If I do all of that and the patient in question doesn't appear to appreciate it, I will feel frustrated. Clearly I am not the altruist I always hoped I was. So whilst I'm sure that this does not apply to all, my hypothesis for the many is this; that to get real fulfillment from a job, whether as a doctor, a teacher or an estate agent, or perhaps even to get fulfillment from life itself, you need to feel valued. In turn, to get the best out of people, you also need to show that you value them. And a chocolate cake seems as good a way as any....

Thursday, 7 January 2010

Battle lines drawn

Back from the Christmas holidays, and so it seems are a host of nasty viral illnesses. They've taken full advantage of our tendency to run ourselves into the ground during the silly season, seeing as many people as we can and giving our viral friends their very own reason to celebrate. It means that my usually peaceful waiting room has been converted into a mass of runny noses and hacking coughs. Their owners have come for antibiotics, and will feel cheated if they leave empty handed.

And so I prepare for battle. The tactics are diverse, the terrain treacherous. There are those who launch straight in with their request, standing over me with a loaded gun... (or is that my imagination?) Others remain under camouflage initially, but are so crushed by my suggestion of paracetamol that they then take up their attack. A few go for a more underhand tactic, comparing me unfavourably to my colleges; "Dr Jones always gives me antibiotics when I've asked in the past". Once or twice I have even heard a patient change their symptoms mid consultation having caught wind of my unwillingness to prescribe.

My defences are limited. Most are already bored of my 'virus versus bacteria' speech and since I have no way of proving to them that theirs is a virus, few are satisfied. Of course there's the strong argument of the need to avoid encouraging bacterial resistance but many won't see this as relevant to them or else they are so bored by my spiel by this point that they have begun to drop off. If I'm getting desperate I do occasionally throw in a few nasty sounding side effects, but those who have used antibiotics before are not swayed by this one.

The fight goes on, patient after patient, and I am tiring. I think to myself how much easier my morning could be if I just signed the prescriptions and got on with it. The temptation is huge, but unfortunately for me my irritatingly pious conscious will not allow it and so by the end of the morning I am battered and bruised, in desperate need of some R & R.

You may wonder why it is that I feel compelled to fight so hard, but there truly are plenty of reasons why we shouldn't be too liberal with antibiotics. Remember the c difficile horror stories of patients dying in their hospital beds from uncontrollable diarrhoea? Antibiotic overuse was largely responsible. It's also worth noting that no new classes of antibiotics have been discovered since the 1960's and so the ever growing problem of resistance really does pose a substantial threat.

Of course I'm being a little facetious as there are plenty of people who are fully aware of these facts and are happy to accept my explanations. Certainly there are also those who actually do need antibiotics and it's clearly always better to check if you're worried. But for those who can do without them, I will continue with my own peculiar war, confident in the knowledge that I am far more likely to become a casualty of the process than they are.