Molly was dying. That much was clear. Her skin was sallow, her eyes half shut. Breathing barely perceptible. She was brought into our A&E department because her family had become concerned about the speed of her deterioration. After her diagnosis with disseminated biliary carcinoma, her deterioration had been swift and merciless. The last few months had seen her lose half her body weight and she was now no longer able to get out of bed, let alone leave the house. Eating had become difficult. The end was near and today had seen a swift decline. She had been reasonably alert during the morning, but had slipped into a coma in the early afternoon.
I examined her and talked at length to her husband and daughter. We agreed that there was little that we could do for her underlying condition. This might be the way-out for her. We would admit her to the hospital and if she survived the next day or two we would find her a place at the hospice if one became available. Our diagnosis was of possible brain-stem stroke or of a catastrophic metabolic dysfunction due to liver and kidney failure.
Everyone, staff and family alike, accepted this. We left the family largely undisturbed. They were looked-after and given tea by the staff, who gave them what support they could in the circumstances. Primarily what we offered was some space and time to be with Molly. The staff empathised with the situation, discussing how difficult it would be of them. Molly’s family were dealt with quietly and left with their dying relative.
Given the sensitivity of the situation – particularly because the patient might die in our A&E department, I asked one of my senior consultants to talk to the family and review the patient.
Thirty minutes later my colleague approached me with a smile. “Molly should be an object lesson for you” he said.
“Why so?”.
“Your patient has made a remarkable recovery. She is sitting up and talking to her family quite happily.”
I was shocked.
“A.B.C.” he asked. “What does that stand for?”
“Airway breathing circulation”. There is no acronym more fundamental in emergency medicine.
“What about D.E.F.G.?”
Oh Lord. I could feel my heart sink.
“Don’t Ever Forget Glucose”, I said.
With Molly, it transpired, a simple and ubiquitous test had been omitted. A test which we do repeatedly on EVERY patient. Not only do we do it, but EVERY ambulance crew does it in EVERY patient too. Yet the BM – the test that gives is a reliable bedside test for glucose – had been omitted by both the ambulance crew, and by the admitting nursing staff and – critically – by me, her physician. Between us, for more than two hours, everyone had negligently failed to record this vital number.
The patient’s rapid deterioration that day was the result of a steep fall in blood glucose. Her underlying condition was indeed fatal – and maybe swiftly so. Yet the rapid and painless administration of some dextrose had raised her, Lazarus like, from her coma – for her to live another day, and likely reach the hospice for specialist palliative care.
I was stunned. I cannot recall ever having missed a BM before. My patients regularly complain that they are jabbed repeatedly – and is it really necessary? Yet for the one patient that really needed it, we had all forgotten it. Although the patient had not come to any harm, a similar omission in different circumstances might have had terrible consequences. If she had been left for much longer, it is possible she would have died earlier than necessary and in the unhappy surroundings of an A/E department. I was – and remain – shocked.
“D.E.F.G.” We even have an acronym for it.
So the question is this: why did I forget glucose when it was most needed? Why did the ambulance crew forget it? Why did the resus staff, who must do 100 BM tests a day, also forget it? What – we must all ask – was going on?
It is possible the answer is both simple and profound.
We were fixated.
We were fixated on Molly’s death. We had created a fixed point, a closure, a truth about this patient. Her diagnosis – when she came through the door – was “dying patient”. And so, we treated her accordingly: with empathy, with the respect accorded the dying, with tenderness, with what we thought was KINDNESS.
And yet, as we can see so clearly from this example Fixation (along with its two cousins Fear and Fatigue) is the enemy of kindness. Letting a patient die unnecessarily in your resus room is the opposite of kindness.
Our fixation had unbalanced our need for both Empathy and Clinical Concern – the two elements of kindness. Our Empathy with the dying had eroded our concern for the living. We had failed to address her clinical problem – because we had become fixed on something else. Fixed on the idea of Molly as a “dying patient”.
Many patients will tell you that this more usually happens the other way around: we treat patients without empathy, as objects, as walking diagnoses simply because we fixate on their diagnosis and then treat their condition. We recognise the “autistic clinician” who promotes our clinical concern above empathy as a stereotype. We fail to treat the patient as a human being by fixating on their disease.
Fixation is insidious, mainly because it is an extension of the way we understand the world. We observe, we categorise, we judge – and then we act accordingly. But fixation, by definition, goes beyond this, because it skips-over the observation and moves swiftly to judgement. As we can see from this example, this fixation doesn’t have to look like snobbery, like prejudice or racism. Fixation is simply holding too fast to an idea. Of seeing the world one way. Of being closed, not open.
Here’s why this is important:
1) Fixation is a huge, unrecognised problem
It is the problem which underlies Mid-Staffs, Winterbourne View and many other scandals of ‘Care’. Patients had become objects, managers had become demons, numbers had become games. No one was willing to see Mid Staffs – an NHS hospital, for lord’s sake – as a killing field. That in itself was fixation.
2) Fixation can be cured.
The solution is ACTS – ASKING, CHOOSING, TRANSFORMING and SHARING – four individual and organisational skills that we need to foster.
There will be more on this in our forthcoming book – www.dutyofkindness.com – please follow the link to secure a copy.
I examined her and talked at length to her husband and daughter. We agreed that there was little that we could do for her underlying condition. This might be the way-out for her. We would admit her to the hospital and if she survived the next day or two we would find her a place at the hospice if one became available. Our diagnosis was of possible brain-stem stroke or of a catastrophic metabolic dysfunction due to liver and kidney failure.
Everyone, staff and family alike, accepted this. We left the family largely undisturbed. They were looked-after and given tea by the staff, who gave them what support they could in the circumstances. Primarily what we offered was some space and time to be with Molly. The staff empathised with the situation, discussing how difficult it would be of them. Molly’s family were dealt with quietly and left with their dying relative.
Given the sensitivity of the situation – particularly because the patient might die in our A&E department, I asked one of my senior consultants to talk to the family and review the patient.
Thirty minutes later my colleague approached me with a smile. “Molly should be an object lesson for you” he said.
“Why so?”.
“Your patient has made a remarkable recovery. She is sitting up and talking to her family quite happily.”
I was shocked.
“A.B.C.” he asked. “What does that stand for?”
“Airway breathing circulation”. There is no acronym more fundamental in emergency medicine.
“What about D.E.F.G.?”
Oh Lord. I could feel my heart sink.
“Don’t Ever Forget Glucose”, I said.
With Molly, it transpired, a simple and ubiquitous test had been omitted. A test which we do repeatedly on EVERY patient. Not only do we do it, but EVERY ambulance crew does it in EVERY patient too. Yet the BM – the test that gives is a reliable bedside test for glucose – had been omitted by both the ambulance crew, and by the admitting nursing staff and – critically – by me, her physician. Between us, for more than two hours, everyone had negligently failed to record this vital number.
The patient’s rapid deterioration that day was the result of a steep fall in blood glucose. Her underlying condition was indeed fatal – and maybe swiftly so. Yet the rapid and painless administration of some dextrose had raised her, Lazarus like, from her coma – for her to live another day, and likely reach the hospice for specialist palliative care.
I was stunned. I cannot recall ever having missed a BM before. My patients regularly complain that they are jabbed repeatedly – and is it really necessary? Yet for the one patient that really needed it, we had all forgotten it. Although the patient had not come to any harm, a similar omission in different circumstances might have had terrible consequences. If she had been left for much longer, it is possible she would have died earlier than necessary and in the unhappy surroundings of an A/E department. I was – and remain – shocked.
“D.E.F.G.” We even have an acronym for it.
So the question is this: why did I forget glucose when it was most needed? Why did the ambulance crew forget it? Why did the resus staff, who must do 100 BM tests a day, also forget it? What – we must all ask – was going on?
It is possible the answer is both simple and profound.
We were fixated.
We were fixated on Molly’s death. We had created a fixed point, a closure, a truth about this patient. Her diagnosis – when she came through the door – was “dying patient”. And so, we treated her accordingly: with empathy, with the respect accorded the dying, with tenderness, with what we thought was KINDNESS.
And yet, as we can see so clearly from this example Fixation (along with its two cousins Fear and Fatigue) is the enemy of kindness. Letting a patient die unnecessarily in your resus room is the opposite of kindness.
Our fixation had unbalanced our need for both Empathy and Clinical Concern – the two elements of kindness. Our Empathy with the dying had eroded our concern for the living. We had failed to address her clinical problem – because we had become fixed on something else. Fixed on the idea of Molly as a “dying patient”.
Many patients will tell you that this more usually happens the other way around: we treat patients without empathy, as objects, as walking diagnoses simply because we fixate on their diagnosis and then treat their condition. We recognise the “autistic clinician” who promotes our clinical concern above empathy as a stereotype. We fail to treat the patient as a human being by fixating on their disease.
Fixation is insidious, mainly because it is an extension of the way we understand the world. We observe, we categorise, we judge – and then we act accordingly. But fixation, by definition, goes beyond this, because it skips-over the observation and moves swiftly to judgement. As we can see from this example, this fixation doesn’t have to look like snobbery, like prejudice or racism. Fixation is simply holding too fast to an idea. Of seeing the world one way. Of being closed, not open.
Here’s why this is important:
1) Fixation is a huge, unrecognised problem
It is the problem which underlies Mid-Staffs, Winterbourne View and many other scandals of ‘Care’. Patients had become objects, managers had become demons, numbers had become games. No one was willing to see Mid Staffs – an NHS hospital, for lord’s sake – as a killing field. That in itself was fixation.
2) Fixation can be cured.
The solution is ACTS – ASKING, CHOOSING, TRANSFORMING and SHARING – four individual and organisational skills that we need to foster.
There will be more on this in our forthcoming book – www.dutyofkindness.com – please follow the link to secure a copy.
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