Sunday, July 15, 2012

On death, and mistaken kindness

Last Saturday, I was put in the unfortunate position of having to break the news of a loved one's death -- not once, but twice -- to the deceased's next-of-kin.

The first was a middle-aged gent who had collapsed at home, likely from a heart attack, and for whom our efforts at resuscitation were unsuccessful. I had earlier spoken to his brother who was waiting anxiously at the ED entrance, and prepped him for the likely poor outcome. Still, he was shocked by the news of his brother's demise, and broke down in tears.

The second patient was a girl who had not even reached adulthood, having been diagnosed with leukaemia little more than nine months ago. Her disease had relapsed despite increasingly toxic chemotherapeutic regimens, and her father had been told that any more radical treatment would be life-threatening in the extreme. She was unwell on arrival, her blood filled with leukaemic blast cells at the expense of functional blood cells, and she suffered a massive intracranial bleed resulting from the inability of her blood to clot. With a bleed that size, she would not survive, and surgery would be futile - all this I explained to her distraught father who had seen her awake and well only hours earlier. She soon succumbed, her father by her side in the resuscitation area, and he looked at me in perplexed disbelief when I told him that his daughter had died.

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I relate these encounters without any disrespect to the dead (may they both rest in peace) nor their families, and not to recount their medical histories, but to reflect on the way their deaths affected me as a doctor involved in their care, and as the person given the difficult task of breaking the bad news of a loved one's demise.

"Difficult" seems overly simplistic, and yet all the other adjectives that went through my mind -- "challenging", "daunting", "thorny" -- fall far from the complexity and depth of the task, and still others -- "unsavoury", "thankless", "painful" -- would make it seem as if the act of breaking bad news was something sordid, to be done and wrapped away quickly and discarded, a soiled sheet that need not suffer the public eye. Yet it is all that and more, depending on the way you perceive death and the way our society perceives it, and how it affects us.

For me, the first encounter was sobering, because I had never been in the position to break the news of an unexpected, sudden death. Most deaths in the ward are in some way expected, the patients terminally ill or decrepit, their families already prepared for the eventuality, just not the timing of it. For a relatively young and fit person, still quite full of energy at the start of the day, to take ill and die within hours, would be a terrible shock to anyone. There is no time to process the gravity of their condition and that death might even be a possible outcome, and then their loved one is gone. So there I was, seated across the patient's brother, trying to break the news to him in what I perceived to be a gentle fashion. Instead I stammered and stuttered, hemmed and hawed, holding the truth just out of his reach before finally, gulping and staring him straight in the eye, blurted, "Your brother has already passed away." And I saw the confusion in his eyes turn to disbelief and terrible grief. In that moment I wondered if there was any way I could reverse time and break the news in a way that would have made things better.

I know there is no way to make death better. It is the end of a life, a finality that crystallises all the things that were and are and could have been and leaves only one truth. I've gone through the death of someone very dear to me and the memory of that moment still replays in my thoughts with no possibility of making it any different. All regrets and what-ifs, hopes and dreams, are made naught by death; and that is what makes it so sad.

Later on, my consultant, who was by my side when I broke the news, told me that I should have just broke the news directly, went straight to the point, instead of going about in medical details which made no meaning anyway, and which only served to confuse the poor brother. At the end of the day, the truth cannot be avoided or covered up by useless words, and it is perhaps even cruel to keep the person in suspense for those few seconds while you try to deal with your discomfort at telling the truth as it is.

I didn't expect that I would have to break bad news again the same day, and for a young girl taken away so quickly her father did not even have the chance to say goodbye. But in a way, the earlier experience had taught me a valuable lesson. Even so, the second encounter would be itself more complicated and heartbreaking that I could ever be prepared for.

After diagnosing the girl's intracranial bleed with a CT brain, I talked to the patient's father for almost half an hour, to relate to him the severity of his daughter's condition, and try to ease him into the revelation (expecting acceptance would be impossible) that she might not survive the next few hours, let alone the day. The difficulty came in the father's tenacity in hoping for a miracle; he kept asking if there was a chance she might stabilise, if there was any possibility that the bleeding could be held in check with transfusions. There I faltered, as I could not take the slim hope away from him. After all, there are no absolutes in medicine. I could only say, "There's always a chance, but in her case, the chance is very, very small." I did not know if he understood the implication that his daughter was almost certainly not going to make it, but he seemed to take heart from my answer, and kept asking the same question, almost as if every time I told him "the chance is very small", it would snowball into a bigger chance. I cannot blame him; who would not grasp at the slimmest hope rather than accept that your child, not yet twenty-one years of age, is going to die? I could not bear to do the figurative equivalent of slapping him and dousing him in the cold reality of death. And it made me wonder about whether this aversion to reality is an act of mistaken kindness (more about this later), something I had similarly been guilty of earlier.

I brought him in to see his daughter, who was progressively deteriorating with the increasing pressures in her brain. Her heart rate and breathing slowed to a still and she passed away within ten minutes of her father reaching her side. My simple statement to him following this, "Your daughter has died." met with a similar look of disbelief, and he even said, "Aren't you going to do anything?" Nothing hurts more to a doctor than not being able to do anything, but doing meaningless CPR on the poor girl would have been a disservice to her, and thus I said, "I'm sorry, but that would be futile."

My senior (not the same person as in the first encounter) later asked me if I had properly prepared the father for the patient's demise, and I related my conversation with him and how he had still doggedly hoped for a miracle. Her reply, "In such cases they will most certainly die, so you should just tell him that." It made me wonder if I was indeed guilty of misleading the father with my mistaken kindness/sympathy, if in withholding the stark facts I had made the loss of his daughter even more painful.

There are no easy answers to these questions, and every such experience is unique in the way humans are, with no one person reacting to such a situation in the same way. Every medical encounter that involves the complexity of human emotions and communication will throw up more questions. And truly, for all that medical school tries to teach "communication skills" with videos and mock scenarios, nothing can prepare you for the raw emotions that death exposes and how to deal with it. So many of us simply avoid it, especially in our Asian context where it is taboo to delve into death, in contrast to Western societies where people may be more open about it. It took me a few days to think back on these two encounters and sort out how they made me feel, and how they have contributed to my life experience. Medicine is still very much an apprenticeship, where skills are passed down from senior to junior, and what you see someone else doing shapes the way you practise in the future, and things get more complicated when you realise that the way some seniors do things may not necessarily be the best way, or even the right way.

One important lesson I took away from these encounters was that my approach towards the issue of death was still clouded greatly by a sense of avoidance. My starting point in both instances was from the paternalistic viewpoint that these patients' families needed to be protected against the painful reality of death, and hence I misguidedy attempted to "soften" the impact of bad news - in the first, with avoidance of the topic and unnecessary circumlocution; and in the second, by providing hope that the father was yearning when there was practically none to be had. While I feel that it is not easy to plainly say doing so was right or wrong -- it is certainly more of a grey area, and involve so many complicated issues -- it likely did less good than I had intended it to. I wonder: 1) if many doctors are guilty of such paternalism and "hiding the truth"; 2) if this is peculiar to Asians due to cultural subtexts involving death; 3) if it is seen in younger doctors and recedes with age and experience, or the reverse. Not having been through many of these scenarios, let alone be present to witness how senior doctors deal with them, I can only rely the advice provided by the two seniors I wrote of above, both of whom seem to have felt that I had not done the patient's family any good by trying to avoid the truth. It gives me much to ponder over.

That's about as much reflection as my brain and the late hour allows me, for now.

Avaris / 7/15/2012 12:26:00 AM

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