An excellent New Yorker expository piece entitled:
Dying words .
In summary, in telling a person they are about to die there are general considerations:
1) There is no right way
2) There are many wrong ways
3) Find a quiet, comfortable, private place where the patient, family and doctor can sit quietly without interruptions.
4) Try to have an idealised script to deliver news so that nothing is forgotten.
5) Avoid bluntly delivering information and just leaving the patient.
6) Involve the patient in the process, to a level they are comfortable with.
7) Explain the details of the disease at an appropriate level.
6) Explain your terminology esp. palliative vs curative, remission.
8) Put prognosis (the course of the disease), into context. Bare statistics do not tell the full story and do not say much about the particular patient.
9) Explain the objectives of palliative treatment
10) In discussing treatment options, always remember to inform the patient of side-effects, and especially side-effects that may be specifically relevant to the patient.
11) Management involves physical AND emotional issues amongst others. Refer to the concept: ars moriendi - the art of dying.
12) Consider advanced or end of life directives to cater for situations where the patient is not competent to consent i.e. ask the patient what they'd like to do in certain eventualities such as the worst-case scenario.
13) Ask the patient what their expectations are. A patient and their family's expectations of death may differ considerably to the actual event. They may need to be prepared.
14) Try to answer patient's questions in as straightforward a manner as posible, avoiding jargon. Try to avoid skirting the truth.
15) Don't discuss the patient with other family or friends without the patient's involvement or consent.

Conclusion: Palliative care operates on many levels alleviating some of the suffering, maximising quality of life and the economic costs associated with terminal illness ( Generally, greater proportion of health care costs are consumed in the last few weeks of life than for any other period). It is worth the investment..

In addition, some other stuff of note:
1) No matter how carefully you discuss the situation with the patient, they will only retain a minority of it, so write the salient points down, or record them on tape.
2) Sometimes the doctor also does not want to let go of the patient and may view death as a failure on their own part.

Seminal works:
On Death and Dying, Elisabeth Kübler-Ross
How We Die, Sherwin Nuland
The Journal of Clinical Oncology, March 2002.

Organisations:
Open Society Institute - Project on death in America
Robert Wood Johnson Foundation - Palliative care centre

Significant people in the field:
Diane Meier
Kathleen Foley

It's odd, Jerome Groopman, who wrote the article has a considerable media presence which lead me to an automatic distrust probably because of the quick fix tv gods such as Dr Phil. from Oprah. Note to self: " I must not make assumptions". Two of his books were the premise for the series Gideon's Crossing, he regularly writes for the New Yorker and holds esteemed positions within the medical community.

No matter how well you think you're getting along with the residents, registrars and consultants, ALWAYS remember to keep the line that separates you from them in mind. Is what I say going to reflect poorly on me?

This week a few friends, Andrew, Eugenie and Michael, received a bit of media attention associated with the Intenational Blog meetup day. Which is good because "they do great work". But there was a touch of regret that I couldn't be down there also. The blog community, well the bloggers I know, are a warm and inviting bunch. I guess the meetup thing made me realise how much I miss those guys and the culture which doesn't seem to exist where I am.

There seems to be an acceptance of that kind pensive culture in Melbourne and it is one of the scenes in which I feel at home. Of the bloggers I know there is a certainty integrity associated with valuing the content without losing a sense of the aesthetic. Though the aesthetic is less important than the message, the format is important in conveying the message. Though admittedly it is the friends more than the culture.

So what was I doing instead? Despite the fear of sounding like a martyr, I'll tell you. Medicine appears to be my life, either in the actual doing or supporting it. The surgeons gave us a few tips today about this very point. One of the surgeons mentioned that one day he just noticed that his family had grown up and he hadn't been there. Medicine seemed to have created a vortex sucking every aspect of life in to it. One of the cardiothoracic guys even went to the extent of saying that his first mistake in making life choices was graduating from medicine. His second mistake was specialising. Though it must be said that this was tongue in cheek. He does in fact love his work and I can see why:

On Wednesday, I held a beating human heart in my hand. Now up until this point I'd viewed the whole surgical process from an almost inhuman technical perspective. Sure it was obvious that we were operating on a person and that we were doing this to improve their quality of life. But it was more from the perspective of the complications and consequences of the operative procedure that their quality of life was viewed. The thought of holding a person's life in my hands had eluded me until Wednesday. And associated with this were feelings of nausea as the chest was being opened through to utter awe, with heart in hand. In a way you can understand how surgeons may develop a God complex. There was a certain sense of power associated with the process. Ofcourse, this also presents a danger in over-estimating your abilities. It's such a fine balance.

Hopefully the above doesn't sound conceited. I'm finding it a bit difficult to adequately explain the process and make it appreciable. I also hope I'm not losing myself in the whole process...

A quote from "A short practice of surgery", Bailey and Love 1943 :

"Ther variety of foreign bodies which have found their way into the rectum is hardly less remarkable than the ingenuity displayed in their removal.

A turnip has been delivered PR by the use of obstetric forceps.

A stick firmly impacted has been withdrawn by inserting a gimlet into its lower end.

A tumbler, mouth downwards, has several times been extracted by filling the interior with a wet plaster of Paris bandage, leaving the end of the bandage extruding, and allowing the plaster to set. "

Surely there's also a chapter on removing foreign objects from the rectums of politicians. Cheap shot but it's so frustrating. This little jibe was prompted by an unpublished internal government report into welfare recipients concluding that 1/6 recipients "enjoyed" being on welfare and had no intention of getting a job. The minister who announced the report, Mal Brough, said ( and I paraphase ) "...well clearly it's not good to have a group labelled due to the behaviour of a minority within that group ("dole bludgers") but lets face it, that's what the community calls them...", or something like that.

I mean, if you really felt it was wrong to label in such a way, Mal, why didn't you say that 5/6 of welfare recipients are fine upstanding members of the community who met their contract with the government in receiving welfare. And surely the government has some responsibility in welfare recipients being unemployed in the first place. What a cop out Mal. Whose interests does that report serve. Not only that, quoting from an "unpublished" report! This is just unsubstantiated bigotted propaganda.

It's so frustrating.....