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

Every Friday, between 5 pm and 6 pm large numbers of patients will be declared dying. This phenomenon- known as the the ‘Cinderella Effect’, is common in hospitals and demonstrates how the human psyche responds to sudden episodes of anxiety. In this case the patients declared as dying will rarely be more sick than the days prior to their declaration. But rather the recognition of dying has more to do with the awareness of the weekend. 

The author, Douglas Adams,* wrote a book titled: The Long Dark Tea-Time of the Soul. It is perhaps one of the best book titles ever written and yet it is the long dark teatime of weekend ward cover that seems a more real-world title. For a doctor the period between 5pm on a Friday and 9am on Monday is a time of missed lunches, frantic running and the bleeping of waist high devices as present now as they were 40 years ago. If there is ever to be a global catastrophe I suspect that the last sound omitted on earth will be that of an NHS pager urgently shouting its message into the emptiness of space. Thus, it is that when faced with an imminent period of absence of medical care for all but emergencies the teams on ward cover across hospitals must decide: who is getting better and who is not. 

Sadly, many people die in hospitals because they came into hospital with a condition that could not be made better. More sadly is the truth that doctors aren’t always keen on recognising dying unless they have to. Medical training is not about recognising dying, it is about making people better. So it is that only when faced with the long dark teatime of the weekend ward cover, do we see a sudden rush to note what has been occurring, observed but un-noted for some time. 

Like Cinderella rushing for the ball room doors before her dress of sequins and silk turns back to rags, so there is a rush to inform families that their loved one who has not eaten all week, or is on their third course of antibiotics and getting worse, is, in point of fact- dying. The cost for the patients who are not recognised as dying on Friday is that they will only need to be recognised by someone who doesn’t know them and may have dozens more patients to see before the end of their shift. The Cinderella Effect is not kind on patients but it is proactive in managing colleague’s work loads. 

Hospitals are 24/7 organisations. But like the sea; they see an ebb and flow of staff during the week. We have fewer staff at weekends and on Bank holidays. This is generally ok, people prioritise and patients generally have comprehensive plans to tide over their treatment. However, some things are not predictable. Instead they may be predictably unpredictable. It is a simple fact of life that dying falls in to this category. Yet recognising dying because of the day of the week is not a practice that stands up to scrutiny. It is tolerated perhaps because there are few who would challenge it. Yet I would say that we are at a medical crossroads when it comes to our treatment of the one inevitability in life after being born. We have a choice as medical practitioners- do we continue to tolerate practice driven by necessity or do we try to accept that uncertainty exists but the longer we give people to understand uncertainty the better they will generally manage it. In other words-do we try to combat a persistent cognitive bias that places decision making around recognising dying until we are forced to make the decision, or do we proactively challenge ourselves to consider it whenever we see a patient who is deteriorating or may not recover despite what we will, or have, tried. 

*Douglas Adams is also the well known author of the Hitchhiker’s Guide series and the provider of the answer to Life, the Universe and Everything. **

** The answer is 42. Thereby demonstrating that human beings, and indeed other organisms, are bad at questions. 

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