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
I’m told that the problem with avocados is that they sit on the shelf for ages not quite ripe, then they ripen for a day and then they spend their remaining time over-ripe and inedible. I feel that a similar philosophy to avocado ripening persists within the hallowed halls of hospitals.
Some people are recognised as avocados by my colleagues. They are going to ripen one day, this day is comparable to the day that we recognise dying. Sadly, it also represents the window of opportunity to make decisions about care, place and people. When the avocado is ripe we know it’s ripe, as with the person-we have optimised every factor and can say without doubt it is ripe. However, should our attention wander or should the avocado not be in a position to shout that it’s ripe- then the moment may be lost. When we next look we see an avocado already past it’s prime. The opportunity to talk with the avocado about its future, the magical window of opportunity, has now closed.
This is a sadly recurrent theme in hospitals. National data from the national audit of care at the end of life (NACEL 2021-22) shows that an unchanging minority are involved in conversations about their own future when dying is recognised. For 33% of people their stay has been 11-30 days before recognition of dying occurs. I should add that when discussing these cases with colleagues across ICU, palliative care and physician roles there is a common theme of retrospective recognition that the signs of dying and, sadly, futility of current therapy- were present in these longer stay patients. The avocados abound in hospitals.
I could argue that when we think we have an avocado we should be preparing the avocado against the day of its ripening but one day is not very long, even in the life of an avocado.
Instead I suspect we need to see more bananas. A banana is a fruit that has phases of ripening. The signs are more clearly apparent when we look for bananas. Perhaps most importantly though is that a banana has time to appreciate it is ripe, it’s future is full of possibility even if those possibilities all end the same way, there are many fashions in which the banana may meet its grower.
When it comes to recognising bananas where previously we saw avocados, I’d recommend using any of the NICE recommended prognostic tools: SPICT, GSF, Amber Care Bundle. But most importantly remembering that we are all bananas and like bananas, some will ripen faster than others, this doesn’t change what they are.
Our patients are not fruit but when considering whether they are dying I suspect an approach that’s more banana and less avocado is the right one. After all, we all want our future to be ripe with possibilities, don’t we?
Also by this author:
Welcome to the department of rebrands.
Creation of a new palliative care ward-a one year retrospective
The problem with predicting the future