If you would, as a fresh-faced medical student, have answered the question as to why you wanted to be a doctor with the words ‘Because I want to help people’, then Margaret McCartney’s new book, Living with Dying, will not make comfortable reading. She has done an alarmingly good job of explaining the aetiology of what many have been aware of for some time — that there is something seriously wrong with the way we practise medicine today. The healthcare system is sick, dangerously so, and this is particularly the case when it comes to end-of-life care.
The book begins with a dramatised account of how end-of-life care so often plays out, and ends with a rerun of how we would like it to were circumstances different. Between these scenarios is sandwiched seven meticulously researched chapters; there are over 450 references. The central chapter is entitled ‘Caring not curing’, and fittingly so since therein is the nub of the problem as McCartney sees it. She describes a healthcare system driven by the illusion that death can be avoided, spending inordinate time and money diagnosing premorbid conditions and identifying risk factors in order to try to avoid the unavoidable. By prescribing ineffective treatments that frequently serve only to reduce an individual’s quality of life, patients are left bewildered and professionals exhausted, such that there is just no capacity left to simply care enough to address what is really important. The situation is exacerbated by a system that practises medicine by tickbox and is underpinned by a fear of litigation if the inevitable should actually take place. And behind it all hover the sinister figures of Big Pharma and political expediency.
There is a helpful chapter on ‘The myth of CPR’ that, as well as raising the question of just how appropriate it is to discuss the matter of DNAR with patients and relatives, gives useful information on the reality of its effectiveness. The book ends with a chapter on the lies we tell and why we tell them at the end of life, and calls for greater honesty with patients. It is only by diagnosing dying and facing the consequences of that diagnosis with our patients that we will be able to maintain hope for a good death and care for our patients well in the process.
This is an excellent book and well worth reading by all who were once fresh-faced medical students and who now wonder just what it was that went wrong. The book explains the critical condition of the healthcare system in which we work and concludes that we must ‘prioritise the things we need to care for dying people’, which McCartney sees as ‘hands on care’ and ‘enough time to do it well’. McCartney believes, with patients and carers united in calling for these priorities, that this is ‘entirely within our grasp’. Earlier in the book she advises against over-optimism when discussing end of life with our patients: let’s hope that she is not being over-optimistic in her hope for the future of the NHS.
- © British Journal of General Practice 2015