By Dr Joseph Hawkins, Consultant in Palliative Medicine, Clinical lead for End of Life Care, Ashford and St Peter’s NHS Foundation Trust. Twitter: @JoeHawk75825077
Step 1: recognition of the Palliative patient.
This is likely to differ depending upon the setting of the patient. Within a surgical setting the patient may have a variety of non-surgically fixable problems. Signs that this has occurred will usually be clear in the notes under the heading-plan: await palliative. In a medical setting the patient may have a longer plan including the use of ‘palliative antibiotics’ and is more likely to have initialisms such as ‘EOL’ followed by -‘tell the patient once palliative review completed’. In some settings the patient may be found in Dante’s first circle of hell-also known as limbo. These patients may be identified by statements such as ‘deteriorating despite all active treatment, guarded prognosis plan-continue current treatment’. These patients are most in need of palliative exorcism.
Step 2: the palliative assessment.
Starting with an explanation as to what palliative care is, usually including explicit statements about not giving morphine to instigate dying and acknowledgement that no-one would treat a dog like this. Secondly provide empathic support and complete explanations of the current pathophysiology and available therapies. This must continue until the following ritual phrase is uttered by the patient or next of kin: “why didn’t I meet you *insert time period here* ago?”.
Step 3: the palliative plan.
This is where instigation of the palliative drugs starts and exorcism of all ineffective medications and investigations occurs. A complete exorcism is not always necessary or desirable. This may surprise un-initiated colleagues. It is best to respond with empathy to their expressions of shock. We also advise tolerance is exercised towards those who repeatedly refer to ‘palliation’. They don’t know better.
Step 4: the palliative exorcism.
The intention of an exorcism is to relieve burdens of disease and illness exacerbated by unnecessary therapies and ignorance of normal dying processes. This may elicit groans and tears from those around as they feel the power of enlightenment. An additional sense of improvement in well-being is to be expected and some patients may be surprised when they start to feel better only hours afterwards. Traditional palliative exorcisms are accompanied by the chanting ‘begone you evil spirit’. However, in more recent times we have noted younger practitioners ignoring this ritual without obvious adverse outcomes. Therefore it is now deemed optional, as are the robes and incense.
Step 5: a good cup of tea.
This completes the ritual and is unlikely to be drunk by you as you go back to step one and repeat; but should be observed nonetheless. Ideally taken with a splash of milk, no sugar and after leaving the bag in for a minimum of two minutes. Other (inferior), options are available.
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