Death

Dealing with death and breaking bad news are among the more difficult aspects of work as a Doctor. Unfortunately here in St Francis it is something you have to do a lot. Death seems to come in waves after a couple of weeks of few deaths suddenly a glut of patients are dying. It seems every few minutes you are taking a relative aside saying ‘I am sorry your father/sister/husband has just passed away’ or ‘I am sorry your mother/brother/wife is very sick they have pneumonia/meningitis/renal failure (generally secondary to HIV) we are going to give them the best medicine and care we can but I think they are going to pass away unfortunately’.

Then there is breaking bad news to the patient themselves. Recently I had a man present with massive right leg swelling and what he claims was a short history of poor urinary flow. A rectal examination reveals a rock hard prostate, blood tests show his kidneys are impaired and an ultrasound reveals in addition to his prostate mass he also has a mass in his bladder. The right leg swelling is secondary to obstruction of lymph drainage by these cancerous masses.

He is a happy cherry man in his 60’s, that is until I try to break as gently as possible (how can such news be termed gentle) that he has advanced prostate cancer and unfortunately there is no treatment we can offer save from pain relief (even that we don’t have a lot of) and a suprapubic catheter if he goes into urinary retention. At that point he breaks into tears. I feel utterly helpless to offer him any comfort, at least if I was his GP at home I could ask him to come back in a couple of days to talk some more, to come if there is any problems, get the hospice involved if appropriate, could communicate more effectively with him without the language barrier. Instead a couple of hours later he is packing his bags to go and I probably won’t see him again. The tragedy of this mans case is that he had previously presented to another hospital and was not diagnosed.

The same day I have to tell a young man in his 30’s some bad news. He is a father of young children, a farmer by profession, HIV negative. He has just presented with abdominal pain and swelling. His liver feels like a massive irregular shaped rock has been transplanted into his abdomen. His abdominal swelling is caused by haemorrhagic ascites (bloody fluid). His diagnosis is Hepatocellular carcinoma. This is a common cancer is this part of Africa particularly in men aged 20-40. The prognosis is bleak. Again I have to explain the same spiel, I am very sorry etc, etc.

Sometimes such conversations seem to pass by in your head without thinking too much, become the same as doing a procedure or writing a prescription. It’s easy to forget that these people are somebody’s husband, father, brother or son. It is also easy to forget that their death particularly if in hospital will put huge financial strain on the family, an income earner may be lost and it is much more expensive to transport a dead body back to the village than a live one.

Death is commonplace here and as such is dealt with differently in the hospital. Staff members often seem unperturbed by the occurrence, resuscitation attempts are rarely commenced (if they are appropriate) and there are no single rooms for dying patients so the family can have peace. Screens are pulled around the bed after the incident but there are no candles or no Chaplin. One of the more humbling aspects of the death is that as the body is being moved to the mortuary all of the bed-siders for the other patients accompany the family there. The women cry and wail as the body passes.

As a doctor there are selfish aspects to death also. Recently whilst compiling mortality statistics for the past two months as I was terrified it would look awful but allowed myself be a little pleased when the ‘mortality rate’ was in fact similar to previous months. Some deaths seem to affect us more than others. Two types of patient tend to die here. The first presents extremely ill and passes away in the first 48 hours, these deaths tend not to affect us much. We didn’t get to know the patient ‘they presented too late there was nothing we could do’

The second presents with complex medical problems is in the hospital for a few days, we get to know them and their story recognise their relatives on the ward round. What limited investigations there are available are done in an effort to find out exactly what is wrong, various treatments are tried, books are consulted at night and thoughts turned over in your head. When they die there is more a sense of personal loss as well as failure. Then there is the frustration ‘if only I could have done this test, consulted that specialist, had the other medication’.

Overall the sad fact is that life expectancy at birth in this country is under 40 years. Several things will need to happen for this to change. Antenatal and perinatal care in the community will have to improve to decrease perinatal mortality. Immunisation programmes will have to be expanded to cover disease such as pneumococcus. There will have to be greater awareness of malaria prevention, safe drinking water and the dangers posed by diarrhoeal disease. The HIV infection rate will have to be decreased through mass testing and education. Health care staff numbers will have to be increased and levels of training vastly improved.

All of this will take money and political leadership, neither of which are in abundance in Zambia at the present.