"Sometimes, it is just about talking"

After worrying about whether or not I am good enough to have joined an acute respiratory team, I took part in a handover in the morning for a patient on the amber care pathway.

The amber care pathway, or care bundle, provides an evidence-based care plan for patients who are acutely unwell. It supports healthcare professionals to ensure that the right decisions are made for and with the patient at the right time. It also indicates that the patient is at risk of deteriorating further or dying. Sometimes the patient improves. Sometimes they don't.

If a patient is on the amber care bundle, the first thing I like to do is to check to see if they have a ReSPECT form in place. This is an advanced directive that tells healthcare professionals what level of escalation a patient would like in the event of them becoming very unwell or needing CPR. My patient did have one, and I could see that she did not want ventilation, CPAP (a machine to aid breathing) or be resuscitated in the event of cardiac arrest. I find it so important to align myself with my patient's wishes so that I know exactly what to do if they deteriorate.

I introduced myself to my patient, smiling as best as I could in PPE. I helped her change her position, and to have a drink. The night staff had only just completed checking her vital observations, so I didn't want to repeat them unless I had to. I did however complete what I consider to be visual observations. I could see that she was cyanotic, and had an increased work of breathing. On the monitor, her oxygen saturations were reading at 80%, despite being on 15L oxygen. This was on trend for the patient, and the medical team were already aware of her low oxygenation.

15L of oxygen is a high flow, and if a patient is not maintaining their oxygen levels in a normal range on this, then if the patient was for full escalation in treatment, we would alter the treatment plan at this point.

However, I already knew that my patient did not want these more invasive levels of treatment, so I instead helped her change her position to aid her respiratory distress. I chatted with her a little bit, but I was very aware that if she was talking, her oxygenation would drop further, so we kept things short and sweet, and I made a point of holding her hand to communicate non-verbally. I was chatting nonsense about the weather, and about Easter coming up - when I get talking I can talk all the legs off of the donkey, not just the hind ones! Later on, she told me that she hadn't cared what I was talking about, just that I was chatting. She said it made her feel less lonely.

I was present when the doctor came in to talk with her. He explained that she was very unwell and that he was concerned she wasn't going to get better. He said that there were a few more treatments that we could try, but he wasn't sure that they would work. He said that if they didn't work we would only be able to make her comfortable.

After the doctor left, I stayed with her and asked if she had any questions.

"I don't understand what the doctor said".

I explained everything again, more slowly so she had time to absorb the information.

"Am I dying?"

I said that she was very poorly, and there was a chance she could die.

"Will you just let me go to sleep?"

I said that if that was what she wanted, we would do that; but that she didn't have to make a decision about continuing treatment right away, and that she could discuss it with her daughter if she wanted.

I told her that her daughter was on her way in, and offered to sit and wait with her. She said she was happy on her own, but asked me to put the radio on. I put classic FM on as requested, helped her with a drink, made sure she was comfortable and ensured her call bell was in reach. I told her that if she needed anything to use the bell, but that we would be in regularly to check on her. I also explained that we had an excellent chaplaincy team if she felt she wanted to see them. ( I had already checked her religious/spiritual needs with her).

After I left her room, my charge nurse sent me for my morning break.

I felt a bit numb. I have imagined this sort of conversation so many times in my head. Sometimes doctors are so busy with all of their patients, that the patient doesn't always have time to digest what has been said, and will very often ask the nurse what is going on with their care. (That is not to say that the nursing staff are not always busy - you don't get holes in your shoes after 4 months not being busy!).

I have always worried that as I am a sensitive person, my own emotions would get in the way of a conversation like this; that they would impinge on my ability to put my patient first. But actually, I felt that my communication was succinct, concise and that I had helped my patient to understand the situation and to feel empowered about her decisions. I had respected my patient's wishes and supported her to deal with the news in her own way.

Overall, I am really proud of the way I handled this situation. I didn't perform life-saving surgery. I didn't perform CPR. I didn't diagnose anyone.

I communicated. I talked, and I saw that my patient needed more time to ask questions and to understand. Ultimately I felt I was able to provide really good holistic care, and I feel really privileged to have had this conversation with my patient.