Signs of Impending Death

The title of this post may sound too medically based, since it seems to focus more on just the signs of death. But having a palliative care doctor assign me this topic to present at our next palliative ward round, I figured it would make for an interesting read.

I was 25 when I witnessed a patient who passed away in front of me. I was still an intern then, and was asked to see the patient in front of many family members. The patient had agonal breathing – periods of deep sighing breathing, followed by long pauses of silence. After a few minutes, the patient stopped breathing at all. Being fairly uncomfortable in such a situation, all I could do at the time was examine the patient, and inform the family that their loved one has passed away.

That was some 3 years ago. I have assessed many more deceased patients since then.

Having used an ebook database, I find out that some of the signs of impending death include:

  • Decreasing cardiac output: increased heart rate, hypotension, cyanosis, mottling, livedo reticularis
  • Renal failure: oliguria, anuria
  • Neurologic dysfunction: decreased level of consciousness, terminal delirium, hypo/hyperactivity
  • Reduced oral intake.

During our palliative ward round, we see a patient who seems to have signs of dying. It was an elderly man who presented due to what appears to be pneumonia. He was drifting in and out of consciousness. He had reduced oral intake. And he looked pale. The man ended up succumbing to his pneumonia, despite IV antibiotics we were giving. Realistically, he didn’t improve after 3 – 4 days of IV antibiotics, and so we had to explain to the 2 daughters that he wasn’t likely to pull through.

I remembered this man from a few weeks back. He was up and talking back then, cracking a few jokes even. I found it hard to believe that he was so well just a few weeks ago.

From what I’ve seen, disease does not discriminate against people. It attacks people of any age.

The Legal Responsibilities

The hospital system is the mash up of many different specialties, all with the common goal of patient centred care; people are sick, so they come to hospital to get better.

With these different specialties, comes different responsibilities, and if you overstep your boundaries and encroach onto a different specialty, there are legal liabilities. Hence, a physiotherapists providing medical advice about orthopaedic problems becomes a legal issue.

I understand why there are such legal liabilities, and in fact, I think these boundaries are necessary to protect patients. But having been in the hospital system, I think it can get pretty ridiculous at times. For instance, at the previous hospital I worked at, an ultrasonographer could mark out the level of pleural effusion, but would not mark the spot for fear of legal liabilities should any issues arise if it was drained. Hence the doctor (usually a resident) would need to come and mark the site that the ultrasonagrapher had indicated. So as a result, any issues with a drain insertion would be blamed on the resident, even though it was the ultrasonographer who technically marked out the site.

In a way, I feel that some of these legal responsibilities leads to a decay in upholding good moral standards. The other day I was asked by the nurse to come and console an anxious patient who had her belonging stolen by an outsider. It was a strange request, because what was I supposed to do as a doctor? I felt that a social worker would have been more appropriate. So I arrived and sat at the patient’s bedside, and started listening.

“Ms X, I’m sorry to hear about what happened to you. How are you feeling?”

“I feel terrible. This everything has gone missing including my phone and all my credit cards. I have at least 12 credit cards in my wallet!”

“Ok. Have you started trying to cancel your credit cards yet?”

“I have Westpac here in Australia, and all the others are in England. But I wouldn’t know how to cancel the cards.”

“Ok, maybe I can try and call the Westpac number and we can try and cancel the card.”

I went back to the doctors desk, and asked one of the nurses if social work was doing anything about cancelling the credit cards. Apparently, social work thought it was not their job to cancel credit cards, and declined to help (it was a Sunday anyway).

Anyway, the dect phone I was holding was too unreliable and kept cutting out, so I ended up asking the patient to come to the doctors desk to use the landline. Partway through, one of the surgical doctors asked me to come into a side office. When I got in, she stated firmly “You need to stop what you are doing. It’s not your role to cancel credit cards, and there are legal boundaries in helping her to do so.”

I had a think about this, and could definitely see where she was coming from. It looks sketchy to say the least when a doctor is helping a patient to cancel her credit cards. Almost like I could somehow financially benefit from the situation. I know I couldn’t do much for the patient aside from listening, so I thought the least I could do was to help her cancel her credit card to prevent someone from stealing her money.

In the end, her daughter arrived, and I quietly left the patient in the care of the daughter.

It frustrates me that because of legal issues, it prevents us from doing something decent. It’s something that I hear about to no end in China, where people are too afraid to help people on the streets who are hurt or ill, due to the fears of legal proceedings against them with false accusations.

But then again, in any system, if things like that are allowed to happen, then people end up changing. If the patient made a complaint against me, or if I was penalized for what I did for that elderly woman, I would be pretty stupid to do it all over again if something similar happens.

Trust

In the field of medicine, trust and rapport are crucial. There is no way you could get a patient to open up anything about themselves, or to even get an accurate history if you aren’t able to establish some level of trust from the patient.

For some patients, this trust comes about easily. For some others, not so easily. It all depends on the patient, and how well the doctor conducts themselves.

Telling patients my name and role gives a great start to establishing trust. Making good eye contact, and a warm smile gives patients the impression I’m approachable, and willing to listen. From then on, starting with something like “what brings you in today?” helps to break some of the ice in the initial encounter. Patients will spend a bit of time on their presenting complaint, and with their talking, they start to establish some more trust.

In general, I have found this to work very well with the majority of patients. The ones this havn’t worked so well on have been some psychiatric patients (more likely the ones who have psychoses) and some patients who seem to hate doctors in general.

What’s surprising to me however, has been how easily at times people place trust in me. I mean, in taking a gynaecological history, I ask females if they have a regular sexual partner. One woman brazenly offered that she and her partner have not been having sex lately (with partner right beside her), and another woman who had menorrhagia offered that she had been refusing to have sex with her husband due to the menorrhagia.

I think that this level of trust can be established, because there is the expectation that the doctor shall treat all information about their patients as completely confidential. We are not even allowed to divulge information about a patient’s diagnosis or medical consult to their partner until we obtain permission from the patient directly. The only time we are allowed to break this confidentiality, is in the case of protecting the patient’s health and well being and that of other people (eg contacting driver licensing authorities in cases of epileptics who continue to drive).

It is expected also, that in getting such information, such confidential information can be passed on to others directly involved in the care of the patient. So, such information may be relayed to senior doctors, nurses, physiotherapy and so on. But it would be a breach of confidentiality to pass on all the identifying information and history to someone like a colleague who isn’t at all involved in the care of the patient.

But at the end of the day, doctors are trying to provide the best care to the patient, and sometimes such private information is required to help provide such care. And I still find it remarkable with how much private information some of the patient’s offer on questioning, something they may not have even told their mothers or close friends. It still amazes me how much trust complete strangers I’ve only met for a couple of minutes place on me.

 

 

On Being Genuine

The other day, my consultant saw me as we were about to do ward rounds and said “Hey doctor, how would you like to do a mental state exam on our next patient while we give you feedback later on?”

That was not a question at all I must say, in firstly, saying something like “no thanks!” would reflect badly on me. So I ended up saying “yea sure!”, and then felt the fear build up inside of me.

So in to the interview room we went, where there were two consultants, my colleague, one medical student, one nurse, one student nurse, and finally the patient himself. The patient himself was a man I had done the admission work for, so I knew his history.He is a man in his 50’s, who was brought in by police from his flatmate in regards to suicidal intent, and alcohol intoxication.

What happened next, was that I proceeded to establish rapport with him, asking basic things like “how have you been feeling lately?”, through a nervous bodily sensation. As I asked a few more questions, I felt more comfortable, and followed up on important cues such as his recent nightmares.

On closing, the consultant told me I did pretty well. He followed up with a few questions, such as “what specifically in hospital has contributed to your mood improvement?”. I wish I had asked that.

What surprised me next, was the consultant’s feedback that I was genuine in my interview with the patient. My interview persona was a reflection of how I interacted with others normally, and in a way, I brought my personality with me as the doctor, to how I am as a colleague.

In a way, it’s something I never really considered, but it’s something I feel is actually quite important. Being genuine with patients is a way of building rapport, and of being sincere to the patient. It helps to establish trust, in that in a way, it lets the patient know a little about the doctor’s true self. And I guess that being doctors, we don’t share our personal life stories, so the patient has very little knowledge about us as a person, other than their first impressions and the personality/persona we display to them. In that sense, to put forth a fake persona to patients, is really in a way distancing ourselves from the patient, in that a mask is worn so that patient’s don’t get to know the person behind the mask.

In a way, I guess my consultant has seen the fair share of other doctors who wear a mask, and adopt a different persona to patients compared to how they are normally. In my view, it isn’t authentic, and it would be difficult to maintain. Perhaps some feel the need to hide their true character between a persona to patients because of the fear of revealing too much? Maybe some try and adopt a more confident persona, or try and tailor themselves as a person similar to the patient to try and build rapport?

Now that I’ve come to it, I think I’d prefer a doctor who showed their personality through in a consult over someone who tried to be someone they are not. Eventually, it’ll show through that they are trying to be someone else.

But it’s definitely something I didn’t consider until now. From now on, I’m going to continue being genuine in my patient interactions.

The Issue of Brain Dead

I think perhaps one of the most horrible things that could happen to someone would be to be ‘brain dead’. Now I’m sorry to anyone if my use of the term ‘brain dead’ is offensive, but I simply don’t know any other way to convey a more concise meaning, without being too wordy. The alternative is something like “loss of higher cerebral functioning secondary to brain hypoperfusion”, which is a handful. I do feel it is less offensive than the term ‘vegetable’ however. So I’m going to use the term ‘brain dead’ throughout. I’ve seen the term used in my medical lectures too, so I’m assuming it’s not necessarily as offensive as it sounds.

The state of being brain dead; it’s a mysterious state – the state of existing, but having no existence mentally.

The person essentially, just exists, sort of like how a desk just exists. The person still has relevant physiological processes occurring, like the body can maintain itself plus a little bit of support from external sources like ventilators, but there is no deeper cerebral function to actually define a brain dead person. The person loses all personality, loses all abilities to make judgements, loses all their emotions, for none of that they can possibly do.

And that is just the tragedy of facing such a situation. A person who once had a uniqueness about them, who had a character and personality that defined them, are no longer there anymore. And it happens so suddenly.

Speaking back from one of the first such patients I had encountered, it was very sad. The patient was in her mid 30’s. Three weeks prior to presentation to hospital, the patient had some cosmetic procedure of varicose vein removal. Two weeks after her surgery, she started getting some leg swelling, and some shortness of breath, but ignored such signs. It wasn’t only until another week afterwards, that when she saw the GP, she collapsed in front of the GP, having cardiorespiratory arrest, with the GP having to provide full CPR. The estimated downtime of lack of perfusion to brain was around an hour. The patient had had a massive PE secondary to DVT developing in her legs.

Investigations I believe, showed her to have a massive saddle embolus, which caused her sudden collapse.

The prognosis from the outset of hearing her presentation wasn’t good. A full hour of no brain perfusion, would certainly lead to irreversible brain damage. Seeing the family was heart breaking, as the husband held his wife’s hand, and ran his fingers lovingly through her hair.

There were hopes of the patient surviving, as there were talks that the patient was spontaneously breathing. But I’m not sure if it was a reliable finding or not.

CT brain scans however, confirmed the worst possible news; there were irreversible brain changes, with loss of white matter differentiation, and changes consistent with someone who was ‘brain dead’.

The thing that makes it so sad is the young age of the patient, and the fact that something so devastating happened from a procedure that had cosmetic value only.

A few days afterwards, I heard that the surgeons were busy retrieving her organs for organ donation. To me, it is very noble of the family to allow organ donation to proceed ahead, and I’m sure no doubt that the doctors bringing up such a topic would have had a hard time in doing so. The fact that someone beloved does not mentally exist anymore, and then to have them get asked whether they would like for doctors to extract all healthy organs would be even more traumatizing.

Seeing the patient during my ward rounds was something that still kept me thinking. She exists in terms of being alive, but she doesn’t exist, because she is no longer who she used to be.

I remember my registrar saying that she hoped this patient dies. Taken out of context, it sounds like something really horrible to say. She added on later “because if she didn’t she’d be continually suffering, and putting her family through suffering.” In that regards, I too had the same wishes as my registrar. The suffering would be too great for her and her family.

Having a Good Laugh Over Faecal Matter

I never realized how little I laughed with the patients in my job until just a few days ago. In our job, we’re always usually seeing a patient that is quite sick, and laughing at times just seems a little inappropriate. Also, depending on some patients, it can be hard to build up enough rapport to crack some jokes with them after just a couple of minutes (in ED, we’d probably only spend 10-15 minutes on history).

One of the patients I was seeing came in with chest pain, and was quite hard of hearing. So I ended up almost shouting my questions. In coming to systems review, I was just asking about bowel motions and urinary symptoms. Here’s how my conversation ended up:

 

“So how have your bowel motions been lately?”

Patient looks at me with puzzled expression

“Are you having any problems going to the toilet to pass stools?”

Still has puzzled expression on face.

“Ok, are you having any problems doing poos in the toilet?”

Patient thinks a bit, and then looks at me with understanding

“You mean how is my shit?”

 

I had a really good laugh after the patient said “shit”. Considering the patient was hard of hearing, and I was shouting my questions at him, I wonder what the patients in the next cubicles would have been thinking, and how disgusted they would be that I was so curious about how my patient’s “shit” was like.

But the man reminded me, that even though in medicine, you face a lot of serious disease, and people who are unwell, it’s certainly nice to have a laugh about things. My patient certainly made the day that much more enjoyable after such a laugh.

 

Bringing Water and Tissues for the Patient

Sometimes as doctors, we can all get too wrapped up in the medical aspects of the patient, focusing on just the medical history, the examination, the medicines that the patient can take to fix their ailments, and so on.

In medical school, we learned about the “biomedical” model. Essentially, this model assumes that illness can be explained by likening the human body as a machine. If something is wrong with the machine, you implement mechanical fixes, so in humans, if something goes wrong, you can do surgery to fix the problem, or you can give medicines to treat the underlying causes of disease. This model however, is not the best model in that it ignores the human mind and the fact that illnesses can be made worse by a patient’s poor state of mind and social situation.

A much better model then, would be the “biopsychosocial model” which also considers a patient’s state of mind and their social situation. It looks at the patient holistically, seeing how their health can be affected by diseases and by both their mind, looking at the interactions between the two to contribute to a patient’s state of health.

But throughout medical school, we learn all about the fancy disease names, the mechanisms and the pathways for producing the disease. There is some education about psychosocial issues, but by far, there is way more emphasis on the “biomedical” model, where the pathology, physiology, and anatomy are honed in on, and which students spend more time studying.

We are trained to view patients in terms of their medical illness. Doctors may refer to a patient when presenting to another doctor as “that guy with appendicitis”. The name isn’t given, but the disease he has is given instead.

In focusing on the medical illness, it can be too easy to forget the human aspects, such as how the patient is feeling, how they are dealing with their illness. In fact, the other day, I saw a patient who had recurrent chest pains, had anxiety attacks, and had a lot of social stressors lately. After excluding possible cardiac chest pains with an ECG, and taking a history, it sounded like this patient was just very stressed. The patient was teary throughout, and spoke in a soft withdrawn voice. To be honest, I couldn’t offer much treatment other than referral to mental health, and just some paracetamol for her headache. In the meantime, by offering a listening ear, a box of tissues, and a cup of water, the patient became more settled, and their partner was full of gratitude at just these simple gestures. In medicine, sometimes just showing compassion and having a listening ear are therapeutic in themselves, and really does help to show the patient that we are not just treating their medical illness and seeing them as a machine, but as a genuine human being with stressors and problems, and with feelings.