In-depth: close encounters with mortality

Good News

For a doctor, success or failure can mean life or death. GP Dr Daria Fielder reflects on close encounters with mortality.

As a career, medicine has surpassed all of my expectations. I realised from the clinical work in my third year at UNSW that this was my calling. The amount of information we had to learn still sends shivers down my spine, but once that’s done, being able to practise medicine is only partially science and the rest is art. The art of being a healer – a successful clinician – comes with many years of experience. I hoped to become a competent doctor, a good diagnostician and a caring clinician. My goal now – alongside
the rewarding role of being a busy doctor and mother of three young children – is to continue growing my practice, which started with just me and now has five outstanding
female doctors and a psychologist.

Good outcomes are frequent and can be as simple as working out why a middle-aged woman has had headaches for the past 20 years. Finding a treatment that resolves her symptoms has a big impact. Or seeing a young woman on the pill who, after a long flight, has a sore leg and picking up that she has clot and treating it early – potentially preventing life-threatening complications.

Sometimes an outcome is really heartwarming – such as counselling a woman who gave a history of being abused by her partner for many years and helping her gain the strength to leave the relationship. Then seeing her in 12 months’ time happy, free and in a loving relationship. Another was a patient bringing her baby to see me at nine months and telling me it was alive due to me, after discussing termination of an unplanned pregnancy and changing her mind. This is not something I can ever forget.

Small triumphs can be very significant – such as gaining the trust of a woman who was so terrified of a pap smear her gynaecologist had suggested that it would need to be done under general anaesthetic. With time and as she got to know me, we spent a lot of time talking about the procedure, why all women have to have it and how one can make it less uncomfortable. This patient even saw a psychologist to help with the anxiety. After some months, when she was ready we were able to do it without anaesthetic.

Good news is always exciting and a pleasure to deliver, however, delivering bad news is a real art not all clinicians are good at. It is difficult of course, however, with experience it becomes part of our daily work. I try to put my feelings aside and focus on the patient. I communicate openly and clearly and provide plenty of time to ask questions and create a plan for the patient. Despite our best efforts, at times things will not go according to plan; patients will get sicker and some will not survive. Learning about uncertainty, death and suffering is part of our training during many years working in hospitals, learning from senior colleagues – not just about medicines, procedures and protocols. As doctors we learn to carry a huge responsibility on our shoulders.

Breaking bad news is not a one-off event but often begins a journey with the patient. For example, a 75-year-old lady presented to see me just before Christmas with shoulder pain and an X-ray revealed a suspicious mass, which was confirmed by further scans as grade 4 metastatic lung cancer. This was just before Christmas holidays and the practice was closed. I called the patient and her husband in for a very long consultation. I explained the findings and what needed to happen and had already organised appointments with specialists and come up with a clear immediate plan. This helped to take the focus away from the gravity of a life-threatening condition and focus on what could be done. Over the next 12 months, I was there for the patient and her husband during great days and terrible days. A lot of my job was to listen, to support and to give advice. My patient has passed away since, however, I still look after her husband. It was my privilege to be there for both of them in such difficult times.

One of the most difficult consultations I’ve had to do was with a pregnant patient who told me that the baby had died inside her womb. She was towards the end and it was her first baby – she was excited, looking forward to welcoming her beautiful baby into the world. When I called her in I noticed something was different about her. Her belly was still distended and she looked pregnant, but I felt tremendous sadness coming from her. I was not prepared and it was a short appointment. I listened, I supported her and came up with a plan.

Gaining consent from a patient to carry out the necessary treatment can be a factor in how effectively we can treat them. A good example is vaccination since sadly some people still believe that vaccinations are evil and there to harm them, despite all the evidence. This fear can drive them to decide not to vaccinate their children, exposing them to risks of disease such as measles, poliomyelitis, meningitis, whooping cough and others. As a parent of three young children and a clinician, it is difficult for me to see these parents making such poor choices and putting their children at risk. However, I understand and empathise that this comes from fear, anxiety and often misinformation. Over the years I learned that all I can do is educate, provide information, answer questions and simply offer to be there and look after their family regardless.

The doctor-patient relationship is that of unequal power, where the doctor is seeing a patient, at times, at their most vulnerable, so it is very important not to cross any boundaries and keep professional at all times. Hugs happen at times, but it’s generally best not to encourage it. Likewise, gestures of gratitude from patients, although small gestures such as a card or box of chocolates over the holiday season might be acceptable. We wouldn’t accept an invitation to a social engagement or a social media friendship request.

In the past I felt very passionate about helping women in domestic violence situations and one of those scenarios resulted in a partner physically threatening me. I have learned to help patients but not to get too involved. Aggressive behaviour towards healthcare professionals is a concern since we do see patients off the street. We don’t know anything about them and then they are in a room with us one on one. When designing my practice, I designed every room in a way that the doctor always sits closer to the door and we have a panic button available in case of emergency. Yet we don’t expect to encounter aggressive behaviour.

Mental health is a big issue – especially getting psychiatric care for a patient since waiting lists tend to be long and there are very few affordable psychiatrists. Mental health is my expertise, but I find it challenging at times; certainly getting help in acute presentations is difficult. Medicating patients and managing conditions such as depression and anxiety is something I do every day.

 

Dr Fielder is a spokesperson for Whitecoat, a new searchable online platform connecting consumers with healthcare professionals. Visit whitecoat.com.au

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