September 1, 2012

Decorating the Dying Process

Image from the Guardian [Link]

Medicine is about idealistic and not even half of it are realistic enough to be carried out in a quest of  treating the sick people. It is indeed a joy to see a patient recover from their illness or surviving the death. Kindly reminder to all; death is not a disease but a process in which everybody shall face it. It’s just the matter of time, event and how someone experience it. In many cases, death is inevitable no matter how hard we try. 

In ideal world, we are talking about a high class management. We talk about transplant for the end stage organ failure, we talk about robotic surgery to improve the accuracy of surgery, minimizing the damage to the patient and speeding up the recovery process. We talk a lot about these drugs and those procedures that we are clinging our hope to. But at the end, how much do we actually do? How many liver transplant that we are able to do while thousands of patient with cirrhosis dies. How many patients that we are able to diagnose them with cancer only at the late stage where we only can offer them palliative treatment?

When i first starts my journey as a doctor just about a year ago, i was a person who trust in miracle and hoping to save everybody. It is a very noble dream indeed. But then, i realize that miracle is not for a doctor even though i experience it.

A patient of mine who was admitted due to the motor vehicle accident was complicated by severe sepsis due to intra abdominal infection. He was very bad and i even council the relative regarding the poor prognosis. Just right after that, he collapse and was resuscitated and undergone surgery. Almost everybody thought that he already develop hypoxic encepalopathy until he slowly recover, able to obey command, talking and finally ambulating with wheel chair. The elements of miracle may exist but it won’t just come as a free bonus. There’s a price that we are all paying for it.

But then, dealing with a lot of patient with terminal illness either due to cancer or medical problem or “death in line” give me a new perspective in a way of thinking. It is not a good feeling since you have to break the bad news to the relative. You have to be patient to their anger, their denial, crying or even excessive mourning. I realize that in many occasion, we as a doctor just should let the nature run it course. The soul who live will shall taste the death.

I learn about few basic things in handling this condition. I probably would say that these are the way how i decorate the dying process in order to make it less painful. First is to assess how much the patient or relative understands about the disease and how it eat them up. After the assessment, it is our duty to make them understand or correcting their misunderstanding. They need to be clear about how serious their problem is. All of this should be done with privacy preferably in a room.

Next is to prepare them for the worst outcome even though they are waiting for us to say that there is a miracle or hope. I believe that they need hope so that they will continue to be strong. It is not wrong because at the end, it is GOD who decide whether someone will alive or die. But to keep telling them that everything will be all right while their special one is dying is a sin. It will only hurt them more when their love one die later. We need to prepare them for the moment.

We have to be firm in pointing professional advise on how far we as a doctor can intervene. Beyond that, they should know that there are limitations that we can do. And they should also understand regarding the “Active” vs. “Non Active” Resuscitation. What i will write here is basically about patient with “No Active Resus” order.

Knowing the fact that their love one is dying, they need something in order to treat their fear. It is time for us to offer them with suggestions. It is definitely will not bring out the patient from the dying process but at least they will be more comfortable. At this point, they are in fear of their love one is in a great suffering. Therefore, we can offer the patient something which is better than nothing. We offer the patient oxygen to help with the breathing part, pain killer for the pain, feeding and space for them to stay with their love one.

The most important thing is our manner towards them. With agony, they are hoping for a comfort. For me, i think that it is beneficial to talk to them in a slow voice, calm and as privacy as we can. If we are shouting, busy with other thing, it will only hurt them more.

And finally, when the time come, i personally belief that we should fully give them privacy to spent with their love one. If the patient is a baby or child, we should offer the mother to hold them because most of them will feel it as a last moment that they want to remember. I will try my best not to disturb them and only intervene to declare death.

At the point where the patient finally departed, there will be a lot of cry, feeling guilty or even hysteria. Some of them may eventually faint. Give them a time before you intervene and calm them down. Offer them a tissue paper and say your condolence. Ask them whether they need any help from your site. After that, ask them politely that your side need to handle the body like removing the branulla or any attachment, cleans any blood or dirt and change the clothes. In medicine, we call it as “Last Office”.

And the most important thing is, all the agreement between the healthcare provider and relative or patient should be documented clearly in the case note. Initially some of them disagree to give signature after the explanation because of their prejudice that signing the document will make them as a cause of death for the love one. Council them properly that this is not with any hidden agenda. It just basically a sign that you understand about the explanation provided by the doctor.

As a conclusion, i would like to stress again that death is not an enemy but it is a road that everybody will walk through it. It is not a disease but it is a process. Dealing with dying process is painful to both patient and relative. Therefore, it is our duty as a doctor to make it more bearable and ease their burden.

1 comment:

  1. hannan khairil anwarSeptember 13, 2012 at 1:03 PM

    brilliant naim!may allah bless you :)


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