OpenIDEO is an open innovation platform. Join our global community to solve big challenges for social good. Sign Up / Login or Learn more

The challenges of talking...

Complex feelings arise for one doctor when thinking about end of life conversations and DNACPR decisions.

Photo of Becky
1 4

Written by

When I was a 4th year medical student I proudly held the student crash bleep and ran to arrests overnight in the hospital. This was what I'd studied for so many years to do. GCSEs, A-levels, pre-clinical medicine - already 7 years of hard work. I was finally saving lives. I was 22 years old. 

But was I saving lives? Often not. The whole experience on the Resus team was pretty grim. I would often end up doing the chest compressions - not being very skilled in the art of the "bag and mask". I broke ribs. The crunches were horrible. I wince and cringe thinking about the feeling of those chest compressions now. I imagined the crunches to be horribly traumatic for the patient (the person, the human being) and they were certainly traumatic for me. The worst arrest calls were running to a far flung ward and attempting to resuscitate an elderly lady or gentleman who had died in their sleep. They had sometimes been dead for a while.  Those attempts were rarely, if ever, successful. And I found them horrible.

But there were definitely some times where we saved lives - on the Coronary Care Unit or in the Accident and Emergency Resus room - where people had a chance of surviving with close monitoring and the combined skill and genius of the Med Reg and the Anaesthetics Reg.

As I got more experienced, certainly by my first year as a fully qualified doctor, the new and exciting experience of running to arrest calls had definitely worn off. I'm a bit of a softy. I like a good chat - about cats and grandchildren and the war. I liked finding out about people. The cut and thrust of the Resus room scared me witless. And crash calls were often scary. I was stressed, very stressed. I cried every weekend I was on call through sheer exhaustion and overwhelm. Maybe I would be better off being a physio? That way I wouldn't feel so responsible when people died. 

Maybe I could do Palliative Care where all my patients were dying anyway? The Palliative Care team seemed like a lovely bunch of people. A casual, corridor conversation put paid to that idea for a while. A respiratory consultant boss of mine, when I asked him what he thought about Palliative Care as a career for me, said: "Oh no. It would be so depressing. You don't want to do that."

So off I went to do a general medical rotation for a few years, to buy a bit of time while I worked out what on earth I wanted to do. I hated the on-calls. I hated the crash bleep with a passion. I retched in the gutter before getting into my car and going to work on on call days. So anxious, so very anxious. I worried about letting my patients down - that they would die because I had made a mistake. I felt guilty and responsible. I toyed with the idea of Radiology or even Anaesthetics. Maybe if I didn't have to talk to people I would feel less stressed? (Oh how little did I realise about both those jobs and what makes a really good radiologist or anaesthetist...)

I carried on retching on on-call days. One younger doctor even asked me if I could be pregnant. I stopped feeling so distressed when I worked on the HIV and Infectious Disease unit of a large London teaching hospital. I stopped carrying the crash bleep. We also had a big multidisciplinary team: including a psychologist and a dedicated social worker. I realised that I really did love talking to people and finding out about their stories. But I also loved the art of the physical diagnosis - working out what the underlying pathology was and working towards improving things. I made people feel better - because I listened, took a careful history, saw what might help and acted. I still had patients and relatives shout at me when they were upset, but I had a team around me and some great leaders to support me. Giving me career advice,  one Professor said: "Be the sort of doctor you want to be. Be a consultant, gather the team around you that you want". He was my Obe Wan Kinobe. 

So off I went to Australia to test out being a Palliative Care doctor - it worked for me. But I still wasn't certain that I could do it forever. I got tired. I got emotionally exhausted. Another fabulous consultant showed me that clinical supervision could help me deal with the emotional toll that being a doctor took on me sometimes. I've had monthly supervision since then until now, 16 years down the line.  It helps me be human and helps me to retain a sense of perspective. I'm more empathic. I take more risks in my conversations with patients because I've practiced them in supervision. I don't shy away from difficult conversations now. I wouldn't work in medicine without supervision now.

I'm lucky - despite having some incredibly hard conversations every day of my working life - about death and dying, hard choices and uncertainty, I have a lot of positive ones too. I still cope with lots of grief and distress and pain.  I get shouted at still.  I'm better at knowing about "what's my stuff, and what's your stuff".  I have learned to protect myself from the effects of feeling other people's emotions - their grief, loss and disappointment. I still sense them, but their emotions don't paralyse me with anxiety and distress. I am helped by my team; a very wicked (often black) sense of humour; safety valves - crying at sad films for instance; supervision; simple comforts - cake, wine, gin, nature, sleep. Sensing other people's emotions helps me care for them more effectively. I use language that I hope they can understand and that hopefully works for them. I use my intuition and gut feelings a lot.

I get it wrong sometimes - the gut wrenching "Oh god, I've pitched this conversation wrong. I'm falling off a cliff" type feeling still happens sometimes. More often though, I get a sense of having had a good conversation. Meaningful and helpful. For both me and my patients. 

Remembering the hideous crunch of the ribs at those early Resus attempts, that sick feeling of being on call and having to make life and death decisions, helps me to support other staff too. I sometimes see a look of fear in other doctors' eyes - senior and junior. "Can you help me with this conversation?" they say (or don't say out loud and they are relieved when I offer to help). I try and support them through the grief, the loss and the really hard conversations. Sometimes we are in the flow, with textbook conversations. Sometimes we muddle through and we learn from each other. 

I'm certainly still very much learning to have conversations which include a decision about DNACPR. Some go well - like the discussion with the gentleman and his wife that I'd been dreading, about a plan for going home and whether a CPR attempt might be a helpful part of his ongoing treatment. We discussed the key elements of his care and decided that a Resus attempt was unlikely to be helpful and certainly wasn't what he wanted. I described a red bordered form that helps share information with all health professionals: "What a good idea," he said. "Can I have one too?" his wife said. 

Some go much less well. Silent gesticulations from a family member sat behind the patient I'm trying to have a carefully-worded, sensitive conversation with. The words mouthed: "No!" The nonverbals add: "Stop this conversation now!"

Some times I get home and I can barely speak. I've had to choose my words so carefully all day. I'm a classic introvert and need time inside my own head to recharge, even though I'm quite an "out there, chatty" introvert. I prefer deep and meaningful conversations, so Palliative Care suits me in many ways. 

I wholeheartedly agree that we must be aiming for clear, meaningful conversations with patients and families about life and death, uncertainty and future planning, with DNACPR discussions as a part of this.

I remember the brutality of failed CPR attempts. They are horrible.  I also remember the emotional toll that failed CPR attempts took on me. I suspect that many of us have a degree of PTSD from some aspect or another of our work, failed resus attempts are probably high on that list. I am probably still carrying CPR "baggage" from the early years.

We must also not forget the emotional challenge of having conversations like the ones I've described, about the end of people's lives. Discussing people's hopes, fears and goals is emotionally hard. As are discussing the technical and practical aspects of dying - why, when, where, how, with whom? All those things ideally need to be done before discussing the final DNACPR red bordered form. 

I don't very often retch with anxiety at work any more, but I certainly go home and replay conversations I've had in my mind. They are difficult to do well. They are incredibly difficult when they don't go so well. Sometimes I am awake at 3am, thinking my conversations through. What could I have done better? How is that person, that human being, feeling now? I'm sure I'm not the only one. 

How can we help doctors to broach these conversations with patients? How can we help people (whether they are patients or not) be ready to have them? 

Tell us about your work experience:

Palliative Care Consultant in the UK. Qualified as a doctor in 1996. Working in Palliative Care since 2000.

1 comment

Join the conversation:

Photo of Bettina Fliegel

Hi Becky.  Great post!  Thanks for sharing your experiences.  I am a doctor in the US.  (Pediatrics) 
I am curious about the "clinical supervision" that you mention.  Is this a monthly meeting with a more senior internal medicine doctor, or palliative care doctor, where you take the opportunity to review cases and perhaps reflect on them in a more personal way?  Thanks again for sharing here!