Detail from cover of ‘The Picture of Dorian Gray’ by Oscar Wilde
When I tell him that his liver is so badly diseased it may not recover, he turns away and looks into the middle distance. There are no questions. He was expecting this. He has probably known that it would end like this for several years, perhaps a decade. But even this foreknowledge could not change his behaviour. He continued to drink, and now, at the age of 4_, he is approaching the end of his life.
I want to ask him why he couldn’t stop. Naïve I know – but doesn’t the prospect of death outweigh the immediacy of compulsion? After all, he was well supported at home; he had every opportunity to arrest the damage in its tracks and live to a decent age. I would like to know why…what was going on in there? But we are well past that now. Serious complications have set in, and all I can do is treat each one as it develops. He clearly doesn’t want to talk about it, and I am not comfortable pushing him.
When all the patient really needs is treatment there seems to be little place for such enquiries. The answers will add nothing; the questions will do no more than suggest to the patient that he did this…he had a choice. In contrast to patients who hold our gaze with a combination of anxiety and confusion, and ask ‘Why me?’, the alcoholic has all the information he needs. Whatever the truth, wherever the blame lies, those factors are irrelevant now. That’s why he looks away. There is nothing to say, nothing to explore.
Understanding why patients made certain choices does not allow us to reach into the past and shake them to their senses, or reveal to them a picture of their future selves – debilitated, jaundiced, desperate. A fortunate percentage will survive their first emergency, and with abstinence will see their liver improve. Some may even be judged appropriate to receive a new liver. But what of those who continue to deteriorate, and who in turning away seem determined to keep their personal truth to themselves? Does this aversion to allowing us beneath the surface impair the quality of care that is given?
It might. Doctors are not brilliant at digging into patients’ private lives or hidden histories. If, through an embarrassment of regret, a patient seems unwilling to discuss the behaviour that resulted in this crisis, the path of least resistance may lead doctors to a superficial degree of emotional engagement. Deeper knowledge of the patient is not acquired, the picture remains sketchy, and empathy does not develop. This may translate to a failure of advocacy. Doctors, who spend their days trying to determine if and when to escalate or intensify care, need to know that the patient wants to recover. They are driven, in large part, by the patient’s expressed wishes. If the patient appears determined to survive, and says as much – ‘I don’t want to die doctor, please do your best to get me through this, I want to deal with this…’ – the medical team is more likely to advocate for intensive care or prolonged support. Patients who remain silent and closed may appear uninterested in their own survival.
I worry that those who turn away deprive themselves of the opportunity to be known or understood, and are subsequently less likely to receive the best that medicine has to offer. The challenge, for those of us who receive them on the ward, is to prise away the (un)emotional armour and find out what they are really thinking. It’s not comfortable, it may feel intrusive, but it is probably necessary.