A Bit of a Smokescreen

Not with real smoke, obviously (I gave up years ago and you should too).  Just a smokescreen to conceal what’s on my mind.  So today I’m letting Dorottya from One Night at the Jacaranda do her thing.  If you’re acquainted with Dorottya, you’ll know how appropriate this is.  And she lives on Bensons.

Dorottya tossed her long black hair over one shoulder and lapped up the attention she always got, especially when she wore bright red lipstick and a Romany-style scarf.

red print scarf

She had removed her wedding band, although she doubted if any man would have noticed had she left it on. Men were such idiots, she told herself while bestowing a dazzling smile on the congregated males.

This she had suspected from a young age. Her theory had been confirmed on leaving her home town of Szeged and going to work for her first family in England. Then, her hair had not been so glossy or so black, nor had her teeth been so white, but modern science could do a lot for mousy girls with stained incisors. English lessons helped, though progress was less about pronunciation and more about fluency in body language. By her third au pair job, she had reinvented herself as a femme fatale, albeit one with impeccable references when it came to looking after young children, helping them play creatively, cooking nourishing meals and keeping house. This last au pair posting was a huge success. So successful that she had been promoted to stepmother. 

“Can I get you a drink?” asked a short man whose eyes were too close together.

As usual the women were much better turned out, thought Dorottya. She giggled strategically and replied “I’ll have pink champagne.”pink champagne

“Bubbly, eh? Just like you.”

She could feel his desperate breath as he handed her the glass.  “Thank you.”  He was repulsive and there was no way she was going to hook up with him, as the English expression went.  Still she lowered her eyelashes as she took a sip. He was no accountant, she thought, because you could end up buying lots of expensive drinks on a night like this without seeing a return for your outlay.  And he obviously hadn’t been speed-dating before, unlike Dorottya.

She sighed.  One was forced to find a little fun from time to time. 

When I’m not Writing

It’s a fun life, this novelist business: publishing and promoting a book, and getting a sequel going, while ideas for the prequel are also bubbling away.

What did I do before novelling?medical bag

A lot more doctoring, for a start.  Every day, the rich pageant of life played out in the consulting-room.  Many patients shared their innermost secrets, told me their darkest fears.  Most had washed, some hadn’t.  Their socks stood up unaided. 

A lot of them talked while I listened to their chests, so I had no chance of picking up the subtle signs learnt at medical school.  Or hearing what they were saying.

Frequently a patient would promise “This won’t take a minute, doc.”  Which was true.   It usually took at least half an hour.   The ones who took longest had often brought me newspaper cuttings about the latest ‘breakthrough’.   Sometimes it was an article I’d written myself. 

These days it’s all about patient-centred medicine.  I realised how far along this road we’d gone when a patient just to ask how feather pillows should be washed.  Some patients, of course, were really ill, like the young man with meningitis who turned up thinking he’d just badly strained his back.   Despite being sent to hospital by ambulance right away, he still ended up disabled. 

doorway to patient's flatWhen I was training to be a GP, I visited a lot of housebound patients.  Finding their homes could be a challenge.  Houses with names were the bane of my life, as were those where the numbers were too small to see from the road.  It was a straight choice:  stop every so often to peer at them, or drive with two wheels on the pavement. 

There were homes so dirty you wiped your feet on the way out. 

And high-rise blocks of flat which smelled of urine and carbolic (but mostly urine).  The lifts never worked, and if they did nobody would have willingly entered them anyway. 

There were tiny bungalows where a lot of patients kept the front door key hanging on a length of string inside the door.   You fished the string out through the letter box and let yourself in. 

Often there were dogs where you least expected them.  There were two kinds: the protective type bared their teeth as soon as you touched their master, and the other kind  stayed curled up on the sofa, unnoticed till someone sat on them.  Then they yelped into life and bit you on the bum. dog

Sometimes the patient was dangerous, like the young psychotic who locked me into the dining room and threatened me with shards of broken mirror.   

It wasn’t a wealthy area.  I’d get called out to see patients with minor injuries, if they weren’t sure it was worth getting a cab to A&E.  Funny they could always afford cigarettes.

The ones that I remember most vividly were the old people, living out their lives in one-bedroomed homes, surviving on their pensions (if they turned the heating down), their memories, and not much else.  They usually had a knitted blanket on their knees, a couple of faded photos on the mantlepiece, some tacky souvenir from a seaside holiday, and maybe a china dray-horse on the window-sill.  While there I’d check the kitchen cupboards.  They were often bare apart from a huge collection of medicines. 

All of human life could be found in patient’s homes, providing insights that are rarely glimpsed 25 years on.  I still see patients, but these days it’s almost always in the consulting-room.  Even full-time GPs don’t have the nearly same volume of home visits these days.  There’s no time in today’s high-pressure, high-tech primary care.  

More Certain Than Taxes, and More Painful

In a few days I’ll be at a Cambridge University event, speaking to students who look forward to careers in the media.  But today I’m looking back at a serious topic.  My piece last month in The Sun newspaper went a bit like this…

Life is complicated, but dying is even more so.

As a doctor I’ve seen many patients whose lives are utter misery.  They’ve reached a stage where nothing can relieve their suffering and make their days bearable.   Some of them beg for death.  But assisting a suicide is against the law in England and carries a sentence of up to 14 years.

If it were the beloved family pet, the answer would be clear and compassionate.

It’s heart-breaking to have a relative who longs to die, and I really feel for the families, especially as my own mother is now suffering horribly. 

My mum’s spine is deformed and broken from severe osteoporosis.  She howls in pain, and in anticipation of pain before even being touched.  She’s incapable of doing anything now.  Every single thing the devoted team of nurses do for her hurts acutely. 

Sometimes she lies in bed yelling that she’s in agony. Or else she shouts over and over “Please help me, please help me.” Mum and me crop

No longer the person she was, she weighs 35kg and stares with blank eyes.  Everything she has been through in the past two years, including a major op that she nearly didn’t survive, has left its mark.  The pain is literally causing her mind to go, but she is still aware of how bad things are.  I sit by her hospital bed and hold her hand, and she sometimes tells me she wants to die.

Increasing the painkillers makes her more confused.  Some of the drugs make her paranoid.  I’m still hoping there’s an answer because it’s so awful to watch her suffer.

Don’t get me wrong.  I was never immune to the suffering of patients in situations like this, but when it’s one of your own you can appreciate the back-story and see the whole perspective of their lives.

Medicine has a lot to answer for.  Many people wouldn’t be alive had it not been for doctors.  On the other hand, medicine isn’t a perfect science and never will be.   I’ve been a doctor long enough to know at first hand that medicine is good at prolonging life, but not so good at sustaining its quality.   

When quality of life is appalling, or treatment too awful to bear, then the balance of pros and cons may suggest that treatment doesn’t benefit the patient.  In making that decision to withhold treatment, the relatives and patient’s wishes are vital.  If the patient can’t take part in the discussion, his previously stated wishes are taken into account.

Withholding treatment is totally different from deliberately hastening death, whether or not it’s with the patient’s consent.    

But there is what’s called the doctrine of double effect.  This makes a distinction between acting with the intention to kill, and performing an act where death is an unintended effect.

For instance large doses of pain-killers can shorten life.  But doctors give them only with the intention of relieving pain. The doctrine of double effect says that’s morally right, even though the primary effect (pain relief) comes with the risk of a harmful side-effect.  Sometimes that harm can even be foreseen, but according to the doctrine it is still OK, as it achieves the main benefit, which is relieving pain.

However the double effect isn’t often the get-out clause it appears to be.  Nowadays there is a huge range of pain-relieving drugs, and dosage changes tend to be tiny, so they rarely shorten life.

Medicine has come so far now that we need an urgent way forward on that most basic event, death.  Not all doctors are agreed on the right course of action.  If assisted dying is introduced in any form, we’d need strict safeguards against abuse, greed, negligence, incompetence, and probably a few other things as well.

Some doctors are vehemently opposed.  Personally I fear that legalising assisted suicide could change the doctor-patient relationship forever.  On the other hand, there’s also the hope that it would help medics honour Hippocrates’ order: “To cure sometimes, to relieve often, to comfort always.”

Since then, my mother has died, ending our suffering, though it continues for other families.