Victoria, a new consultant, pushed for the procedure. It was, as they say, a ‘multi-disciplinary decision’. A consensus had been reached and the views of all those involved was clearly documented, but it was Victoria who made it happen. She had seen that Mr S. would go nowhere until a decision was made. Due to the complexity of his situation (a chronic disease with a rare complication), touching several specialties, there seemed to be no leader in his management; no overall owner. So, Victoria, who had met Mr S. several times and felt that she knew him quite well, decided to ‘own’ this episode of care. Through emails, corridor chats and a couple of cameo appearances at specialty meetings, she brought Mr S. to the eve of the procedure.
It was performed rarely, in any hospital, and Victoria, being no surgeon, did not know exactly how it was done. Nevertheless, the surgeon who agreed to do it (reluctantly, she felt) was known to be an expert. There was risk; how could there not be, given the complexity, and the proximity of the pathology to the brain? But the surgeon would explain this while obtaining Mr S’s informed consent. Not that Mr S. had much choice. To do nothing would see him die of the complication at some point in the next 12 months.
Victoria went to see Mr S. on the morning of the procedure. She didn’t see it as her business to delve into the risks, and she knew that Mr S. had given his consent already. A porter was waiting by the nurses’ station with a piece of paper in his hand asking which bed Mr S. was in. It was time for him to go to theatre. So, with the porter circling the bed, Victoria wished Mr S. well and promised to see him in a couple of days. Not tomorrow; that might be a bit too soon. Mr S. nodded. His smile was not full. Victoria got the impression that he had more knowledge of the procedure than she did.
Victoria walked away feeling pleased with herself, for steering her shared patient through the Byzantine processes that can seem to slow the progress of patients in the NHS. Mr S. was getting what he needed, at last.
Next day Victoria headed straight to clinic. She was too busy to think about Mr S. At lunchtime he crossed her mind. He would probably be in the ICU now, recovering; or, if everything had gone very smoothly, on the specialist surgical ward. Over lunch she looked him up on the computer. Yes, still in ICU.
On the way to her afternoon commitment she ran into the surgeon.
“How did it go?” asked Victoria, brightly.
“Didn’t you hear?”
“He stroked out, massive embolus came off the aorta. The whole left cerebral hemisphere is swollen, the neurosurgeons had to do a craniotomy overnight.”
“Alive, yes, but there may not be much…” He tapped his temple.
Victoria stepped back, and leaned against the wall.
“Are you OK?” she asked of the surgeon.
“Me? Yeah, fine. Tiger country, you know, that sort of operation.” He walked away, unflustered.
Victoria was distracted all afternoon. Her body language was automatic, her responses generic. She knew it would not be helpful to anyone for her to visit Mr S. He was being looked after well enough.
On the way home, through the blurred background and streaky lights visible from the train window, she saw Mr S’s future. It was nothing like she had imagined. It was not what she had promised him.
Now she regretted her assertive approach. It was due to her negotiating the blocks, driving the reviews, nudging the co-ordinators, that Mr S. had been listed for surgery. Her prints were all over this process. She felt responsible.
The residual weight of that responsibility, a leaden blanket, slowed her down as she walked home from the station. Her husband asked what was the matter, and she explained. He, a non-medic, saw it another way. There had been no wrong done here. The operation was indicated, all were agreed. It was bad luck… a final bit of bad luck compounding a life afflicted by bad luck. Victoria nodded and smiled. Yes, that was the rational approach.
Because Mr S’s clinical needs had changed, Victoria had no ongoing role in his management. Other patients displaced the acute concern she had developed for him. His name appeared in a morbidity and mortality meeting, but his ‘outcome’ generated no controversy.
Later, long after he had died, Victoria met other patients who needed strong advocacy from someone to take their management forward. Sensing that these patients were entering territory full of risk, Victoria did what was required of her, offered her opinions, and contributed to the consensus. Although the speed of decision-making was often slow – or deliberate, a better word – she was comfortable with that. She did not push things forward. Let management plans evolve at their own pace. Byzantine processes have developed for good reasons. Sure, there might be occasions where she needed to lead from the front and make things happen – in those areas where she was the acknowledged expert – but in other circumstances, from now on, she would go with the flow.