Blog 26. Mutandis mutatis: Transitions mapped and unmapped in palliative care

By Deans Buchanan

Mutandis mutatis 

Mutandis mutatis – “making the necessary changes” – can be straightforward when both what needs changed and why it needs to be changed are clear and defined. In times of a novel virus pandemic, we find ourselves more in the company of topographers – adapting and navigating change overuntrodden ground and unmapped territories. Necessary change into the uncertainty of “the where”, “the what” and “the how” is simply hard and arduous.

In 2020, society and individuals have experienced “driven change” not “chosen change”. This change was driven by the new presence and impact of the SARS-CoV-2 coronavirus – there is no doubt this has been difficult journey in many aspects of health and social care.

In some ways change is both a natural state and an unnatural state. In 1854, Claude Bernard proposed that “the fixity of the internal environment is the condition for free life” and yet we also know homeostasis is a constant balancing act between dynamic processes – “fixity” achieved through dynamic balancing acts. Bernard was describing the “milieu interior” (the internal environment) we see this year that the desire for stability is played out collectively but can be very much challenged by change in the external environment.

Although the sense of disruption has been collective this year, COVID-19 brought a type of imposed change where we have all found our bearings challenged and our tools to navigate change challenged. At the same time, it is worth reflecting that such life-changing, life-altering, fixity-destroying events occur for many people every year, in all walks of life, through the new and unwelcome presence of serious illness. Working in palliative care, it is easy to see that fragility of stasis is inherent in human experience of life.

This mixture of holding on to what we know whilst rapidly embracing necessary reformations, transformations and deformations is a concentrated version of the normal mundane adventure stories of our everyday lives, concentrated and amplified in a collective sense but with each individual needing to find their own balance. Our human experience is usually informed by varying tensions between domains of importance, significance, constraint and choice. Even our responses to this experience are found “between”: bitter-sweet, happy-sad, lost-found. We live our lives and we end our lives in the hyphen: tensed between, fixed-changing.

Pan-demos – affecting all the people

When we step back and look at our shared experiences of COVID-19, there are not many other things in life that so profoundly affect us all, but there are some. Death itself is intrinsically pandemic to the human condition. It is the recognition of our shared humanity and our common mortality from which palliative care begins. A palliative approach seeks to alter illness processes where possible and to manage the consequences of illness when such underlying processes cannot be changed. The consequences of advanced, serious or incurable illness ripple through lives in ways not dissimilar to our collective pandemic experience. Change you did not plan and do not control comes into all the domains of human experience – physical, social, financial, practical, spiritual, psychological, emotional, meaning, role and connections.

Transitions to, and from, are journeys – it would seem we are still at the beginning phase of this journey. We have more to learn, more to adapt to and more to navigate. We have a greater sense of what is needed but much remains outwithcertainty. We can and should reflect that this is a natural state for many people facing life-changing illness and then draw deeper empathy, understanding and realism from our experiences so that collective support can flourish in new ways. Here there is space for learning and growth – for lasting gain in our approach to how we care for and support each other as we face ill-health and as we enter the final chapters of our stories.

We should take clear-headed lessons from this and acknowledge that facing towards realities of change allows us to best navigate these, but everyone will journey in their own mode, at their own pace and guided by their own values. Collective reality contains space for individual stories.

For me, I hope that within this year I have learned more about the depth of what we can do to respond together to unexpected challenges, that the sense of the collective approach is clearer in our minds as being more powerful than individual effort; but also that we see we don’t control everything, limits exist and mortality is part of the normal fabric of life.

Seeing what is needed is one step, but working through the necessary changes will require focus and effort – mutatis mutandis.


Dr Deans Buchanan

Deans trained in medicine at the University of Glasgow and also undertook a BSc (Hons) in pharmacology. He completed his medical doctorate from the University of Dundee in 2010 on the unmet supportive care needs of lung cancer patients. Following his specialist training in Palliative Medicine in Tayside, he was appointed to a Consultant post there in 2011.

He is currently Lead Clinician for NHS Tayside Palliative Care and played a key role in the recent establishment of the Tayside Palliative and End of Life Care network.

Deans was a member of the Council of the Scottish Partnership for Palliative Care from 2014-2020, currently co-leads the newly established Scottish Network for Acute Palliative Care and was appointed as the Palliative Medicine Specialty Advisor to the Chief Medical Officer for Scotland last year.

In addition to this, he is the co-director of the Master of Public Health (Palliative Care Research) programme at the University of Dundee and is an honorary clinical tutor for the University of Dundee.


Image copyright: Divya Jindal-Snape

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