Katie Holroyd, M.D.
Partners MGH/BWH Neurology resident,
PGY3
12/09/2019
From my experience thus far in American hospitals
(acknowledging the limitation that I have trained exclusively at large,
academic institutions in major east coast cities), there are two main types of
deaths we see during training. The first is the unexpected, often catastrophic death
from large strokes, traumas, cardiac arrhythmias, or other non-reversible
conditions. These scenarios often involve prolonged codes, extensive
resuscitation attempts, and utilization of a vast amount of resources in the
emergency department or on a hospital floor. The second is the slow and
deliberate transition to death, which can be referred to in many ways including
comfort care, hospice, or palliative care.
This often occurs in older patients in whom additional diagnostics or
treatments would cause more suffering than benefit, and takes place after
extensive delicate discussions with family members (or at times the patient
themselves). Regardless of the way that death occurs in the hospital, it is
usually an intensely private experience, with patients moved to single rooms and
all measures taken to support and respect family members during the transition.
It has seemed to me, that death in the US is almost never
viewed as inevitable until the very last moments, and that death without
extreme investigations, treatments, and resuscitation is the exception not the
rule. In contrast, and with the
disclaimer that I have very limited understanding and experience in Zambian
culture after only one month, attitudes about death in Zambia seem to exist in
an almost paradoxical fashion.
On one side, there are far fewer open medical discussions
about the transition to death here. Countless patients who would be in an
intensive care unit the United States lie in regular beds, and with one look
any medical professional could identify that they will not make it out of the
hospital alive, especially given the limited resuscitation resources here.
However, these thoughts are not relayed directly to family. This comes in part
because there is generally no acceptance of withdrawing care in Zambia. As discussed in my previous post, families
provide most of the direct care to patients in the hospital, and concepts such
as stopping feeding (even if a patient is unable to swallow) or withdrawing
medications do not exist. A palliative care service was briefly formed by some
of the residents at UTH, but it was not accepted by patients, other physicians,
or hospital administrators and was disbanded. Several of the residents here
remain interested in performing projects to help better understand attitudes
regarding palliative care, with the hope of re-instating this service in the
future.
Contrarily, I have found death to be much more visceral, present,
and commonplace here than in the United States. Far more of my patients here die,
and die at much younger ages, than patients I see in the US. Often at least one
patient I saw in the morning will have died by the afternoon. Sometimes this is
expected in our sickest patients, but at other times, such as the 28 year old
man who walked into the hospital with only a cranial nerve palsy one week
earlier, it is very unexpected. These patients are passing away in shared rooms
with 8-12 other patients, and thus there is no way to not be faced with death
on a daily basis either for the physicians and nurses in the hospital, or the
other patients and their families. In this sense, by force of necessity, death
is directly witnessed much more frequently than in the US.
 |
CT of the head showing an
old stroke as well as evidence
of neurocysticersosis infection |
I have also found families ask far fewer questions
surrounding a family member’s death—rarely questioning why, how, or making
accusations of medical misconduct at any point. Whether this is based on
language and cultural barriers with an American doctor, lack of medical
literacy, or something else, I cannot say. However, it seems that many Zambians
have been forced to experience death as a very real part of life, without extensive
questioning or complaining. I can imagine this is due both to differences in
life expectancy (61 in Zambia, compared to 78 in the US) and larger family size
(average number of children in Zambia 5.5, compared to 1.9 in the US).
Importantly, I do not in any way mean to convey that
families in Zambia are okay with a patient’s death. In fact, the grief rituals
here involve wailing, screaming, and falling to the ground at the patient’s bedside,
which last for many minutes and can be quite traumatizing to nearby patients.
I really have no other word to describe the fact that
Zambians must experience a far greater proportion of preventable deaths from
infection complications of chronic illnesses, and lack of resources, than unfair
. However, it has made me wonder
if the American—or if not American, at least my personal—tendency to avoid,
resist, deny, and disbelieve the inevitability of death, may at times do more
harm than good.
