Kindness and effective care depend on close observation: reflections from a deathbedBMJ 2022; 377 doi: https://doi.org/10.1136/bmj.o1155 (Published 06 May 2022) Cite this as: BMJ 2022;377:o1155
Much of good care is little things, things that are not heroic and are not measured, but make all the difference between good and poor care. Unintended lack of kindness might be something like giving a dying person tea with milk when they drink only black coffee. This happened to my mother, and something similar, but a bit more serious is happening now with my mother.
My mother is close to death. Indeed, she looks more like a corpse than a living person. I sat with her for some four hours yesterday, and mostly she was calm, sleeping, and just occasionally groaning. But as time passed she became more uncomfortable. The nurse and I debated whether she should have a small dose of morphine. The obvious discomfort she felt when turned decided me that she definitely needed an injection. The nurse agreed, but the whole process took time because they have to get two qualified nurses to inject morphine.
I wondered if even a small dose of morphine might kill her, but it didn’t. She became calmer, but the effect began to fade. I suggested that they might give her another injection, but they said that they would have to wait for four hours. I expected that they would give the injections regularly during the night.
When I arrived this morning my mother was clearly distressed. They were planning to wash her. I said that I thought that they ought to give her an injection before they did so and asked if she had had an injection during the night. The nurse didn’t know and said she would check the system and added that she would have had an injection “only if the nurse thought she needed it.” The nurse came back a few minutes later and said how she hadn’t had an injection. I pointed out that it’s better to prevent pain than try and treat it when it’s arrived.
They agree that they will give her an injection and suspend the washing until she’s comfortable. Unfortunately, it takes about 30 minutes to assemble two nurses. During that time I suggest that they might give her twice the dose they gave her yesterday. The nurse says she’d have to get a doctor’s permission to do that, and, as this is a care home there is no doctor available.
As it happens, it appears that the nurse hadn’t read the instructions left by the palliative care team. They can give twice the dose she had yesterday, and she can have it every hour if necessary. They gave her the injection 10 minutes ago, and the morphine is having its sweet effect.
Nobody here is unkind. The nurses and carers want to do their best, and they show their kindness by offering me tea every few minutes. But to be effective kindness needs close observation and a thoughtfulness that probably eludes most of us. The nurses and carers live as well in terror of the “rules, the system,” especially when it comes to opiates. Lack of close observation and the need to follow the rules have unnecessarily led to suffering for my mother. But now she is very calm in the embrace of Morpheus.
A week later: That last dose of morphine was enough. My mother didn’t need any more and died peacefully 15 hours after that injection. My brothers and I prepared to celebrate a rich life filled with love and caring, and her death has led me to reflect on the world’s most difficult job, being a mother. https://richardswsmith.wordpress.com/2022/04/13/the-good-enough-mother-the-greatest-invention-of-the-20th-century-reflections-after-a-mothers-death/
Competing interests: none declared
Provenance and peer review: not commissioned, not peer reviewed