Like Isaiah’s God, the general practitioner must become ‘a man [or woman] of sorrows and acquainted with grief’. The general practitioner is privileged because the nature of family practice brings direct involvement with a relatively constant group of people over a long time. This gives exposure to a broad gamut of human emotions: boredom and excitement, worry and relief, joy and sadness. There is opportunity to experience vicariously the whole of life from birth to death.
A demanding aspect of patient management for the family doctor is terminal care in a home environment, in particular when a man is cared for by his wife. In my experience this can lead to another phenomenon seen only in general practice that I call ’widow rejection’: a sudden and obvious dismissal—a coldness in attitude toward the attendant doctor—by the new widow. The once-friendly and (self-confessed) dependent woman apparently terminates the relationship; the expected and inevitable death of the husband creates a post-mortem distance, which might never be bridged.
Is this phenomenon real or imaginary? Is it oversensitivity by the doctor in what is an emotional situation? I think it is real.
Mr C, a retired builder, lived with his wife in an attractive cottage with a large garden area; their only daughter was in another part of the country. I attended him through progressive cardiac decompensation: hypertension; ischaemic heart disease; severe angina; attacks of paroxysmal nocturnal dyspnoea; total cardiac failure; and then a slow orthopnoeic death. His care demanded much attention day and night for months. The couple had insisted on terminal management at home without nursing help and it became distressing for both of them in the end.
Mrs C seemed cold toward me thereafter.
Mr R and his wife lived in a well furbished villa unit. They were most fond of each other, although she was the dominant partner and could be demanding. Their one child, a son, had been estranged for some time.
I had been their family doctor for years when Mr R developed cerebrovascular atherosclerosis with gradually increasing dementia, although at first he was merely absent-minded and forgetful. My visits became more frequent.
Death was sudden. Mrs R remarried not long afterwards and no longer sought my counsel.
Mr and Mrs D were comfortably placed and lived in a pleasant home complete with swimming pool. They had no children and late in married life adopted twins. Mr D was a heavy smoker and, as seemed almost inevitable, developed lung cancer. I had looked after them always and this couple, too, insisted on terminal care at home. Mrs D did all the nursing; they were very close and he wanted no one else involved. The deterioration was protracted and painful, but my frequent visits and the use of narcotics ensured the final stages were not too distressing for any of the family.
However, Mrs D saw me infrequently afterwards.
Mr and Mrs S had escaped across the Balkan frontier during a snowstorm one night in 1945. Their daughter lived at a distance and a strong bond endured between them through their hard-working life into (finally comfortable) retirement. Mr S had long-term vascular problems; hypertension had led to vertebrobasilar insufficiency and then peripheral vascular disease. His only hope of avoiding leg amputation was arterial bypass surgery. Despite the risks of anaesthesia, the vascular surgeon and I pushed for the operation. He came through it successfully but did not survive a postoperative cardiac arrest.
Mrs S refused to accept his death and the once warm relationship with her GP was terminated.
How can we explain such rejection?
On review of these cases, a pattern emerges. Two people are close to each other for a mixture of reasons: they are childless or have only one child at a distance; or share a background of emotional and physical hardship. These circumstances have led to a particularly interdependent relationship, usually with a dominant female partner allowing a ‘third party’ to care for her failing spouse. A ménage à trois of sorts is formed.
DISCUSSIONS AND LESSON LEARNED
The examples illustrate the evolution of an unhealthy situation in medicine. An attempt should have been made to involve others—a partner in the practice, social worker, district nurse—so that the burden could be spread more widely. The stricken couple might resist such a suggestion, but I see no other way to prevent a tolerable situation becoming one of soul searching, paranoia, hurt and resentment.