Further Confessions of a GP

Playing God

I’d been called out for a home visit to see Miss Blumenthal, a 94-year-old lady who was living in one of our local nursing homes. I had never met her before, but I had visited other patients at this home and it didn’t have the best of reputations. The nurses who worked there were nice enough, but the organisation was poor and the big company who owned the home seemed to run it purely to make the maximum profit. It was always understaffed and the nurses and carers were paid a pittance. Any competent members of staff moved on quickly to better employers, leaving a few stragglers who would perhaps struggle to find any work elsewhere.

I stood ringing the doorbell for several minutes before Carmela, the nurse in charge, finally opened the front door for me. She looked very flustered.

‘Sorry, Doctor, lunchtime always very busy, busy.’

Carmela was Filipino and her English really wasn’t great.

‘So, what’s been going on then, with Miss Blumenthal?’

‘Miss Blumenthal not been eating or drinking for last few days,’ she told me, reading from a scrap of paper she’d pulled out of the pocket of her tunic.

‘Anything else you can tell me?’

Carmela studied her scrap of paper for any further information but there was clearly none. ‘I’ve been off the last few days,’ she shrugged.

‘Best go and see her then, shall we?’

Carmela led me through a network of corridors and fire doors before we reached Miss Blumenthal’s room.

‘Hello Miss Blumenthal, I’m the doctor.’

Miss Blumenthal opened her eyes briefly and mumbled something in a foreign language.

‘She used to sometimes speak to us in English, but she doesn’t any more. She only speaks to us in Polish now.’

This wasn’t unusual in people with Alzheimer’s. Even if they are completely fluent in a second language, as they slip further into dementia, they almost always lapse into speaking only their mother tongue. Carmela was wrong about the language she was mumbling in, though.

‘She’s not speaking Polish, that’s Yiddish.’

Carmela looked at me oddly: ‘But is say on her record that she is Polish.’

‘She may well have been born in Poland, but she’s Jewish and the language she is speaking is Yiddish. It’s actually closer to German than Polish.’

Carmela nodded, but looked at me suspiciously, as if I was trying to play some sort of odd trick on her. I sat on Miss Blumenthal’s bed and held her hand. She opened her eyes and I smiled at her but her look remained completely vacant. She mumbled something, again in Yiddish. Yiddish was the first language of my great-grandparents. It was once the common language of Jews all over Eastern Europe, but has now pretty much completely died out. The only words of Yiddish I know are ‘shmuck’ and ‘chutzpah’, neither of which were likely to have any great value in the current situation.

I turned my attention back to Carmela. ‘So, Miss Blumenthal doesn’t communicate much these days, but what can she do when she is well?’

Carmela again looked at me as if I was asking some sort of trick question.

‘I’ve never met Miss Blumenthal before, so I need to know how she is normally,’ I explained patiently. ‘For example, a couple of weeks ago what could she do?’

I was met with further awkward silence, so I tried to clarify things further.

‘Could she walk and eat and go to the toilet by herself?’

‘Oh no, Doctor,’ Carmela replied, relieved that she had finally got to grips with my line of questioning. ‘She used to sit in lounge, but not any more.’

‘So she’s bed bound.’

‘Yes, Doctor.’

‘And she’s incontinent of urine and faeces.’

‘Yes, Doctor.’

‘And occasionally she mumbles away in her language but doesn’t seem to understand you?’

‘Yes, Doctor.’

‘And you have to spoon-feed her puréed meals?’

‘Yes, Doctor, but last few days she is refusing to eat or drink.’

Carmela was smiling now, relieved that we seemed to have at least partly bridged what had once appeared to be an impassable chasm in our ability to communicate.

‘Does she have any family?’

‘Nobody. There is a nephew in Canada but we haven’t heard from him in years.’

Miss Blumenthal closed her eyes again and lay passively as I examined her.

As I rolled up her sleeve to check her blood pressure, I saw a series of green numbers tattooed on the inside of her left forearm. I stopped cold. It was a concentration camp tattoo. I had only seen one once before, but it was unmistakable. She opened her eyes and caught me staring dumbstruck at her forearm, but there was still not the slightest glimmer of expression in her face. In the relative peace of her nursing home, I couldn’t possibly imagine what horrors she must have witnessed 70 or so years ago in a Nazi concentration camp.

I remember as a medical student speaking to another patient who survived a concentration camp. He described a Nazi doctor separating the new arrivals into those who looked well enough to work and those who looked too weak. He was only 15 years old at the time, but the doctor chose him to live and placed his parents and little sister in the line that went straight to the gas chambers. I spent many hours after that conversation wondering how any doctor goes from learning about saving lives to choosing which people live and which die in a death camp. Looking at Miss Blumenthal’s tattoo, I wondered if she had faced some such doctor all those years ago. Had that doctor looked her up and down and chosen her to live?

It was now my turn to make a decision about Miss Blumenthal’s future. It was a different time and place, but in some ways there were stark similarities in the decision-making process. I was a doctor deciding whether I believed Miss Blumenthal might be able to survive the next few months. I was having to try to place some sort of value on her life and then make a decision based on my conclusion. Unlike the Nazi doctor, I’d like to think that my decision was going to be based on compassion and kindness, but it was still a massive decision to make, the significance of which wasn’t lost on me.

‘Does she need to go to hospital, Doctor?’ Carmela asked me.

‘Well, yes and no. She has stopped taking anything orally, so unless she goes to hospital for intravenous fluids, she’ll get dehydrated and die.’

‘I’ll call an ambulance, Doctor.’

‘Hold on. She’s 94 years old with advanced dementia and very little of what could be considered quality of life. She can’t walk or communicate or toilet herself. She may also die in hospital regardless of the fluids. It might be kindest to keep her here rather than have her end up on a trolley in a busy emergency department.’

‘What do you want to do, Doctor?’

‘Well, really we should make a team decision. You and the staff here have been looking after Miss Blumenthal for some years now and knew her when she was less unwell and less demented. Have you any thoughts about what she might have wanted in this sort of situation? Did she make any sort of living will?’

Carmela continued to look at me with an expression of confusion. The idea that she could and should be part of this important decision-making process had clearly never occurred to her. As far as she was concerned, I was the doctor and this was my judgment to call and mine alone.

I had been working in A&E only the day before and it was absolute mayhem. There were trolleys of patients stacked up in the corridor and security guards wrestling with burly drunks in the waiting room. If one of my patients really needs hospital treatment, then the busyness of the hospital wouldn’t be a deciding factor, but I really wasn’t convinced that hospital was the best place for Miss Blumenthal – she faced what was undoubtedly the final phase of her life. Whatever my misgivings about the nursing home, her room was calm and peaceful, the surroundings were familiar and the staff were caring.

‘Okay, I’m not going to send her to hospital. I’m going to sign a “not for resuscitation” form and the plan is to keep her comfortable here.’

‘What if she gets worse, Doctor?’

‘She probably will get worse. I want you to make sure she’s comfy, encourage her to take fluids and food if she’s not refusing, and if she seems to be getting into any sort of distress or pain, I’ll write up a syringe driver for morphine.’

Doctors are often accused of playing God. My decision not to send Miss Blumenthal to hospital could be perceived as giving her a death sentence, but I don’t see it that way. I was simply accepting that she was coming to the natural end of her life. In an ideal world the patient, family and medical staff are collectively involved in these sorts of tough end-of-life decisions. Unfortunately, sometimes that just isn’t possible and someone like me has to step up and make a judgment.

End-of-life decisions are never easy, but I couldn’t help feeling that my decision was even more emotive given the struggle for survival Miss Blumenthal had faced all those years previously. I knew nothing of her life between then and now but I’d like to think it had been worth the fight. Perhaps reaching 94 years old should even be considered a poignant victory over the evil that had nearly ended her life 70 years earlier.