The drover’s wife

The registrar called about her first consultation as a trainee oncologist. The “case” was a 69-year-old previously well woman (let’s call her Tracey) from a semirural setting, who had gone to bed, one week ago, as normal, and had then woken up to find she was having difficulty holding her coffee mug. Within 24 hours she was intubated, ventilated and transferred to a metropolitan centre. A week later she had been diagnosed with a severe demyelinating polyneuropathy and metastatic squamous cell cancer of the lung.

We reviewed all the data, spoke to other members of the team and agreed on a plan of supportive care and withdrawal of ventilatory support. The next difficult task was communicating this to the patient. Our only method of communication was that she could answer yes or no by blinking her eyelids: one blink for “no”, two blinks for “yes”. We went through why her condition precluded effective treatment of her cancer, and that we were recommending “keeping her comfortable”. We asked if this made sense to her — two blinks.

The family conference was shaping up to be a nightmare. The family had no time to come to terms with the situation, the diagnostic pathway was complex, and different family members were coping at different speeds. All the medical teams involved were represented: intensive care, respiratory, neurology and oncology. The sheer number of people involved, the formality and foreign environment all made for a surreal experience. Each team took their turn explaining the situation. The talk was of nerve conduction tests and ventilation, electrical impulses and biopsies, but the news on all fronts was technical and dire. Eventually one daughter had had enough — “I can’t cope with this anymore”, she cried. Feeling helpless, one of the team took her hand, and said “It’s OK, it’s OK”. “It’s not OK” was the inarguable response.

Then we tried a different approach — “What sort of person is Tracey, what is she like? Is she the sort of person who knows what she wants, is she a strong person?” The sobbing slowly eased. “Strong”, her husband guffawed. “If she was here I know what she would say to you all — bugger off.” We all broke out laughing, and the atmosphere changed. Tracey’s husband went on to recount some stories about her, demonstrating her resilience, independence and free spirit. We were able to then lead the discussion to talk about her wishes and their alignment with what her medical teams and family wanted for her — not to suffer. The meeting closed with some sort of “resolution”. The family spent some quiet time with her, painted her nails, cut off some locks of her hair to keep. They recounted their stories of her life. A day later, ventilatory support was withdrawn and she died peacefully.

The stories of Tracey reminded us how difficult it is to find the real person behind the intubated woman who could only communicate by blinking. Thinking about the Australian sense of resilience and love of plain speaking, the image of Russell Drysdale’s The drover’s wife came to mind. Not as a stereotype of laconic Australian humour, but as a celebration of the incredible strength and resilience of ordinary people. We often struggle with what to say under circumstances like these — and what could we say that was reassuring? How much do we try to couch things in euphemism, versus speaking plainly? How do you establish a family’s preferences? Here we were given a very good indication that, in this family, speaking plainly was preferred.

Shifting the focus to Tracey as a person also allowed the family to tell us about her and made them the experts. It helped us all deal with the fear and grief involved. Engaging in a conversation based on this information allowed us to develop a plan that was centred on her needs and wishes. This “drover’s wife” taught us about the strength of the Australian character in colourful terms. We could only listen, smile and, in respect of her wishes, “bugger off” to let her die with her family.

Russell Drysdale. The drover’s wife, c.1945. Oil on canvas, 51.5 x 61.5 cm. National Gallery of Australia, Canberra.