Teaching and Learning Moments
A few months ago, I participated in an elective with a nursing service in a small, desert town. The town has only one sealed road and is more than a 12 hours’ drive from the coast, in the heart of the Australian Outback. The town has long since dwindled from a significant farming center into a place where the train passes through but never stops. Doctors visit the town, but it is a different doctor each week and the doctors are not very involved in the ongoing care of patients.
One patient I encountered during my placement was in the final stages of his life. When I met him, he gave me a weak smile and told me that he was pleased to meet me. I was welcomed by his family and got to know many of his extended family in the two weeks I was there. The patient was suffering from bowel cancer, which had perforated through the bladder wall, producing an ileovesical fistula. A urinary catheter was repeatedly becoming blocked by fecal material. Medications controlled the pain and nausea he suffered from, but he had not been out of bed in weeks. As a medical student I was able to accompany the nurses to the patient's home to assist with the drug infusions, the catheter, and the dressing of his bedsores. His condition subsequently declined to the point where he was awake for only a few minutes each day and then, shortly after, he died. The entire town population of 300 attended his funeral; such was the popularity of the man.
In observing at close hand the final days of this man's life, I found myself reflecting on the delivery of effective medical care. This patient was experiencing the success of medical care: medications had controlled his pain and his nausea, and he was able to stay in his own home with his family. His ongoing care consisted of twice-daily visits by one of the four local nurses, all of whom he had known personally as children—a far cry from the sterile, impersonal environment of a hospital ward.
Dying patients are probably the most intimidating patients a medical student encounters. Even as we approach qualification and beyond, palliative care wards seem less inviting than general medical or surgical wards. They seem to represent a failure of what medicine is all about—finding a cure or, at the very least, stable ongoing management. However, being involved in the palliative care of this patient was extremely rewarding. His death was more dignified than many I have seen in major city hospitals. It took a small in town in the remote Outback for me to learn what matters most in health care.