Benjamin Daniels - Further Confessions of a GP

I remember as a medical student speaking to another patient who survived a concentration camp. He described a Nazi doctor separating the new arrivals into those who looked well enough to work and those who looked too weak. He was only 15 years old at the time, but the doctor chose him to live and placed his parents and little sister in the line that went straight to the gas chambers. I spent many hours after that conversation wondering how any doctor goes from learning about saving lives to choosing which people live and which die in a death camp. Looking at Miss Blumenthal’s tattoo, I wondered if she had faced some such doctor all those years ago. Had that doctor looked her up and down and chosen her to live?

It was now my turn to make a decision about Miss Blumenthal’s future. It was a different time and place, but in some ways there were stark similarities in the decision-making process. I was a doctor deciding whether I believed Miss Blumenthal might be able to survive the next few months. I was having to try to place some sort of value on her life and then make a decision based on my conclusion. Unlike the Nazi doctor, I’d like to think that my decision was going to be based on compassion and kindness, but it was still a massive decision to make, the significance of which wasn’t lost on me.

‘Does she need to go to hospital, Doctor?’ Carmela asked me.

‘Well, yes and no. She has stopped taking anything orally, so unless she goes to hospital for intravenous fluids, she’ll get dehydrated and die.’

‘I’ll call an ambulance, Doctor.’

‘Hold on. She’s 94 years old with advanced dementia and very little of what could be considered quality of life. She can’t walk or communicate or toilet herself. She may also die in hospital regardless of the fluids. It might be kindest to keep her here rather than have her end up on a trolley in a busy emergency department.’

‘What do you want to do, Doctor?’

‘Well, really we should make a team decision. You and the staff here have been looking after Miss Blumenthal for some years now and knew her when she was less unwell and less demented. Have you any thoughts about what she might have wanted in this sort of situation? Did she make any sort of living will?’

Carmela continued to look at me with an expression of confusion. The idea that she could and should be part of this important decision-making process had clearly never occurred to her. As far as she was concerned, I was the doctor and this was my judgment to call and mine alone.

I had been working in A&E only the day before and it was absolute mayhem. There were trolleys of patients stacked up in the corridor and security guards wrestling with burly drunks in the waiting room. If one of my patients really needs hospital treatment, then the busyness of the hospital wouldn’t be a deciding factor, but I really wasn’t convinced that hospital was the best place for Miss Blumenthal – she faced what was undoubtedly the final phase of her life. Whatever my misgivings about the nursing home, her room was calm and peaceful, the surroundings were familiar and the staff were caring.

‘Okay, I’m not going to send her to hospital. I’m going to sign a “not for resuscitation” form and the plan is to keep her comfortable here.’

‘What if she gets worse, Doctor?’

‘She probably will get worse. I want you to make sure she’s comfy, encourage her to take fluids and food if she’s not refusing, and if she seems to be getting into any sort of distress or pain, I’ll write up a syringe driver for morphine.’

Doctors are often accused of playing God. My decision not to send Miss Blumenthal to hospital could be perceived as giving her a death sentence, but I don’t see it that way. I was simply accepting that she was coming to the natural end of her life. In an ideal world the patient, family and medical staff are collectively involved in these sorts of tough end-of-life decisions. Unfortunately, sometimes that just isn’t possible and someone like me has to step up and make a judgment.

End-of-life decisions are never easy, but I couldn’t help feeling that my decision was even more emotive given the struggle for survival Miss Blumenthal had faced all those years previously. I knew nothing of her life between then and now but I’d like to think it had been worth the fight. Perhaps reaching 94 years old should even be considered a poignant victory over the evil that had nearly ended her life 70 years earlier.

‘Yeah, just a quick one for you, Doctor. I need you to refer me to see a psychiatrist.’

‘Right, so why’s that then?’

‘Is that any of your business? I just need to get referred and then you can get on with your day and I can get on with mine.’

‘It doesn’t really work like that. If I’m going to send you to see a psychiatrist I need to be able to explain in the referral letter what specialist help you need. I need to have done an assessment of your mental health and to consider that the severity of your condition is beyond what I as a GP can manage.’

Simon, the young man in front of me, was well dressed and held my gaze with a calm self-assuredness that bordered on cockiness. He didn’t look depressed, anxious or psychotic. He had never been to see me before with any mental health problems and I couldn’t for the life of me fathom his sudden desire to see a psychiatrist.

‘Look, Doctor, I’ll be straight with you. I’ve got myself into a spot of bother and my solicitor says that the judge will look on it favourably if I can show that I’m addressing my anger issues.’

‘What have you been charged with?’

‘Well, they’re trying to pin me with racially aggravated GBH, but it was self-defence and I’m no racist. I mean, I went out with a half-Chinese girl once, so how can I be racist?’

As Simon aggressively declared his innocence, I discreetly tapped his name into Google and read the local newspaper’s record of events. According to witnesses, he had had a dispute with a taxi driver, who he had pulled out of the car and punched unconscious. Several witnesses stated that as his victim was lying face down in the road Simon continued to kick him in the head while calling him a fucking dirty Paki. Clearly everyone is innocent until proven guilty, but I was struggling to find empathy with the man sitting in front of me. He was still blaming everyone else rather than showing any remorse and he certainly wasn’t expressing a genuine desire to address any underlying mental health issues he might have.

‘Look, Doctor, I could lose everything here. If I get done for this I’ll lose my job and I’ll have a criminal record for life. I could go down for two to three years.’

I managed to resist the overwhelming desire to tell him that he should have thought of that before he decided to kick a man’s head in. I could feel my blood pressure rising and a little voice at the back of my head told me that I was letting my emotions get in the way of the consultation. I needed to treat this man with impartiality and without judgment. A legal declaration of his guilt or innocence was yet to be made and as his doctor it was my duty to treat his medical needs regardless of anything else. I took a deep breath, and blocking out any personal feelings of dislike I had towards him, I returned to thinking about the primary medical needs of my patient. He wasn’t unwell physically and although it could be argued that anyone with such violent tendencies must have some underlying mental health issues, these clearly weren’t currently something that he had any desire to address. In summary, I could justifiably tell him to bugger off.

‘I’m not going to be able to refer you to see a psychiatrist on the NHS. The psychiatrists have got a really busy caseload as it is with lots of very mentally unwell people in this town. I would only refer you to see a psychiatrist if your mental health merited it, not because it might help you in a court case.’