The End?

How do we decide when the time is right for us to go? Can you imagine making the rational decision that now was the moment for it, now was the time for your life to end? With all the current controversy over euthanasia, mercy killings and the right to die, I thought I'd looked at end of life decisions from every angle, but in truth I've never really been able to imagine the reality of what it must be like to make that call. This week I saw it.

It started with a telephone call from a lovely elderly couple who were requesting a home visit. Mr Jenkins' belly had swollen up dramatically over the course of 2 days and they were getting worried. "He wont to go to hospital" were amongst the first words from Mrs Jenkins' mouth, "but perhaps there is something that you can do?"

I don't know this couple well, but there is something about them that I find inspiring. Mr Jenkins has been immobile since a stroke 5 years ago and as a result, relies very heavily on his wife. She too, however, relies heavily on him, and the strength of their relationship is palpable. They are always kind, respectful of each other's needs and above all incredibly loving. They are a pleasure to visit, and treat me like their long lost daughter when I do.

Today, however, I could see that they were frightened. They knew a little of what might be going on, as this wasn't the first time that this had happened. The explanation behind Mr Jenkins' massive abdomen was that his bowel had become obstructed and air was now filling the bowel like a balloon behind the blockage.

They loathed hospital. The waiting around, the not knowing, the helplessness. They asked me if his condition was life threatening, I told them it was. With tears beginning to fall, he looked at his wife and asked to stay where he was.

I found it hard to witness the emotional exchange that followed, feeling as if I was intruding on this grief-stricken couple whist they made the most agonising of decisions. If he stayed at home he was choosing to die, we all knew it. It was upsetting and yet, despite my awkwardness, I did get a sense of how privileged I was to be there with them.

I think he had made his decision, but his wife had not, and I could feel her agony as she sat down, head in hands. They wanted my advice and, feeling as if I was betraying him, I told them that my advice was to get him to hospital. The truth is, that whilst I knew he was desperate to stay at home and knew that there was a good chance he might not return from hospital if he were to go, I just couldn't let him stay. Bowel obstruction can be a particularly distressing way to go and I didn't want them to go through it. It was their choice of course, but I knew I was influencing their decision.

The ambulance came, took him to A&E and he's now on a surgical ward feeling helpless and miserable, just as he knew he would. He is alive, and his wife was brimming with gratitude when I spoke to her on the phone, but I wonder if he is so thankful? Should I have kept quiet and done whatever it took to follow his wishes, even if I thought he was making a mistake? Was I acting in his wife's best interests and not his? Was I acting in mine?

Popping Pills

Yesterday a man in his 60's came to see me with knee pain. He had a diagnosis of osteoarthritis, or in other words, wear and tear of his joints. He knew that the condition could only be treated symptomatically. He knew that there was no way of reversing the process and no real cure apart from replacing the joint. He had always refused, however, to take any painkillers, claiming that he believed in the body's innate ability to heal itself. Now he wanted a referral to the surgeons for joint replacement.

It struck me as really odd that this man would prefer surgery to taking tablets, but he's not alone. There seems to be an ever increasing proportion of patients who don't like the idea of taking medication. Whilst they're often happy to consume vast quantities of echinacea, arnica and all number of unknown 'supplements', be poked and prodded by tiny needles or pay a fortune to be put into a trance, the idea of taking conventional medicine is akin to ingesting poison.

Despite what you may be thinking, I am not a pill pusher. Indeed I am completely in favour of taking as few medications as possible, as infrequently as possible. Nonetheless I do find it hard to understand this deep mistrust of conventional medicine. Why do so many believe in therapies which often have little scientific basis and almost always no real evidence behind them, whilst those treatments tried and tested under the most rigorous conditions are somehow feared.

There is also a belief, I think, that conventional or 'Western' medicine is in some way unnatural when compared to the complimentary therapies. A feeling that the medications are artificial and as a result could damage the body. Yet huge numbers of our most commonly used medicines are sourced from natural products: penicillin from a fungus, morphine from poppies, digoxin from the foxglove, aspirin from the bark of a willow tree.

So what's the big problem with conventional medicine?

Stuck

Although my career in General Practice is still in its infancy, the majority of my consultations are pretty unsurprising. What I mean by this is that although each consultation is very different, the same sort of conditions appear again and again. Tennis elbow, indigestion, heart disease, coughs and colds, back ache, all the usuals. On the whole, people present with conditions I'm familiar with, and which I can deal with (or at least try to) fairly confidently.

Just once in a while however, someone comes through the door with something completely surprising. Something which I have absolutely no idea how to handle. A 20 year old presenting with aggressive and dangerous behaviour during sleep (he woke once trying to smoother his girlfriend), a hand that suddenly swelled up like a balloon for no reason, a sixteen year old faking an asthma attack.

This week's surprise was a charming elderly Japanese couple, presenting on behalf of their daughter. They entered nervously and told me their story. Their daughter Jasmine, aged 30, was a patient of the practice. She had come over from Japan to study in London and was happy and settled. About a year or so into her studies, she had met an American with whom she travelled to New York. The American was heavily dependent on marijuana, and Jasmine was now using too. The last contact they had had with their daughter was a terrifying phone call during which she shouted and swore at them, spoke of 'the voices', and threatened to harm herself if they came to find her. Some family friends in New York had also reported increasingly strange behaviour from Jasmine when they had attempted to contact her on several occasions. Jasmine's parents were frightened and distressed, and as her doctor, they had come to me for help.

What on earth could I do? I so desperately wanted to help these terrified parents, but how? After talking to them a little more, it became apparent that what they were really hoping for was advice from a psychiatrist about the best way to handle the situation. A perfectly sensible idea - but how to achieve it? They didn't have the money to pay for a private consultation, and the idea of our psychiatric services accepting a referral like this was far fetched. I could see no way of helping them. I gave them a few telephone numbers - Relate, Citizen's Advice Bureau etc, but without any great hope for a solution. They left showering me with gratitude, but I have never felt so inept and frustrated in my life.

She is my patient. She is an adult and has chosen to go to another country where she is now in trouble. She is not seeking my help, but her parents are. Apart from a genuine desire to help, do I have a responsibility to? Is there anything I could or should have done?