Mrs P lived around the corner from me in a semi-detached house. She was in her late 80s, and her memory had completely gone. But she managed, and she knew that she wanted to stay at home.
We started getting messages from her neighbours stating their concerns about her. It's a small community, and we do have a social role. I went to see her. She was doubly incontinent every day. The place was ramshackle and fortunately I have a poor sense of smell.
She had a niece who made it possible for this to continue by coming in and cleaning up every day. I did not question how she could be so devoted.
Things went on. I respected that this old lady desperately did not want to leave her home except ‘feet first’. And she had help.
But the neighbours continued to write complaining letters.
The neighbours were journalists. They now said Mrs P walked out on the main road at night. She was a danger to others and herself. She might set the house on fire. If anything happened, they would make sure we got the blame.
I reluctantly contacted the psychiatrist. She came to see Mrs P with me. Yes, she agreed she was demented and at risk. She would arrange to section her for an assessment.
They took Mrs P away and put her on a locked ward at the geriatric hospital. Two weeks later she died.
Her house went up for sale. It has now been painted and done up.
Jeff was younger than me, that is, in his early 30s. He was a heavy drinker. The last time he had been into hospital they had found he had varices surrounding his oesophagus, which could rupture any day.
When he came to see me I had a student visiting for ‘Country GP Day’. I renewed Jeff's prescriptions, and talked with him, responding to his nonchalance in a matching nonchalant way.
It occurred to me while doing this that the student might think that as far as secondary prevention was concerned, I might be missing the boat.
Before he left I said to Jeff, ‘You're killing yourself, you know’. He flashed back, ‘I know’.
I saw Jeff only once more. I was passing a pub on the green behind my house. I often did this on walks, and occasionally saw patients I had urged not to drink sitting outside. This was not the place to talk, and I passed by.
A few months later we got a message from the hospital. He had been admitted with bleeding varices and had died.
I only saw Miss B about twice. I was new to general practice, and had not learned to manage such things.
The first time I saw her she had a cough and weight loss, so I ordered an x-ray. The thing that most concerned her was her sister, who was blind and who depended on her.
I saw the patient again after her lung carcinoma had been confirmed. I explained the diagnosis in a routine consultation. Again, her main concern was, what would happen to her sister?
She died shortly afterwards. I am not sure whether my partner or anyone else saw her. Her sister did manage on her own.
Before working in NHS general practice, I had worked for a short time in a Canadian family practice. Doctors charged for short or long consultations separately. They also had a charging category for counselling, which might include, for example, breaking bad news.
It struck me then, and later when my father had cancer, that although this was mercenary, it worked.
NHS doctors, including myself, manage about twice as many patients as doctors in many western countries. In addition, we are exhorted by our College and rewarded by the NHS to prevent disease. To achieve this we encourage patients to do or not do all sorts of things in order, for example, to improve their lipid profile. This is fine, but it's icing on the cake.
What about the GP's role in helping families manage a good death? Perhaps it is considered a bit downbeat for the College to exhort it, or too crass for the NHS to reward it. It's a bit like being ‘patient-centred’. We can assume it will be provided like strawberry pie. But when it comes to it, it's not.
Cancer is now a priority when it comes to taxpayers' funding, and the subject of a Special Service Framework. But GPs do not get ring-fenced/rewarded time for providing good terminal care.
But when I'm old and sick I want to stay at home, and have a GP write me down regularly in her visit book.
- © British Journal of General Practice, 2005.