Death by drowning

Of the many ways to die,

Drowning, I imagine has to be one of the worst.

It is bad because it doesn’t happen immediately –

There are the seconds – minutes before unconsciousness takes over; the realisation even before the air stops of what will happen, then, the process itself – the panic, the fear, the desperate attempt to do something before…

It can’t be fun.

That’s all I’ll say.

We talk about a good death.

To most of us this doesn’t need explanation – sure, it is person-centred and will vary between individuals, but here, I suspect are some of the elements:

Pain-free

Family or friends

Favourite music

Warm

Gentle

Private

Your affairs in order

That kind of thing.

One of my patients died recently. His family were present, I don’t think he was in pain, he was likely warm. Music wasn’t playing, and he didn’t have adequate privacy.

He didn’t get to see his dog before the end.

That will stay with me.

Modernity has imagined all sorts of ways to interfere with dying – from ventilators, bypass machines and dialysis to oxygen supplies, intravenous additives and endless medicines.

Yet, we, that is the humans, or, any living thing, remain powerless. I find this reassuring. No matter how big your car or dominant your country, you, like me will one day die.

I am often caught-up in the end times when modernity, or perhaps better put, medicine, gets in the way, when it shifts from being a prop to an obstacle. When the oxygen mask is blowing dry air into your mouth and all you want is a drink. When the doctor or nurse at three in the morning is fiddling for the fourth time to insert a needle into your collapsed vein, when, all you want is sleep. When the medicines are dispensed, totted-up in a little paper cup and offered to you with Weetabix, and, you baulk at the notion.

Hurdles. Obstacles. Barriers to a good death that is the right of every person.

‘Doctor, their blood pressure is 200/120, what should we do?’

What is the correct response:

10mg of Amlodipine?

Repeat the test?

Ask, ‘What is wrong? How are you feeling?’

Panic?

Ask, ‘What am I doing? Why am I doing? Is the measuring helping my patient who is 96 and, staring at the wall opposite?’

We throw pathways at hospitals and clinical care – if this, then that, blood pressure low – do this, too high – go here; don’t stop at Go, pass direct to the bleep system, call for assistance.

Pathways are however, very often, the antithesis of person-centred. They take the experiences of the majority and create a map, a what should happen when, so long as you aren’t too unusual or, we haven’t measured you wrongly or the pathway belongs to someone else with a different condition.

It is like squeezing in to too small shoes. It can be done, it is awkward and, you can get about, but you look odd and you will soon get blisters.

Pathways stop up thinking, they allow hospitals to flow, as if patients are rivers and their lives water.

Jump in the boat and sail to the sea; what happens when you are paddling up-stream?

Pathways stop you thinking.

We used to have something called the Liverpool Care Pathway – I remember asking the doctors to follow the guide when my mum was dying, to stop with the needles and scans.

Eventually, like every test or standard given to the NHS, managers and teams of clinicians busied themselves and found ways to optimise the pathway – not so it was optimum for the person dying, but ideal for the system – to minimise variation. Soon, people were on conveyor belts and the love related to the original work was twisted into something ugly.

Equally, unwarranted variation is the enemy of quality.

The NHS has different challenges and resources in every area. Although the folk living on the Bishop’s Avenue are likely to pop in to BUPA for their care, if they break their ankle it is the local A&E they will approach.

The landscape is varied between deprivation and privilege, disease levels and lifespan, there is no consistency, there never has been and there is unlikely to ever be, at least until our society evolves. Yet, we can still expect unvarying care and attention, love and support.

We all deserve a good death.