Do Not Stand At My Grave And Weep.
I am not there. I do not sleep.
I am a thousand winds that blow.
I am the diamond glints on snow.
I am the Sunlight on ripened grain.
I am the gentle autumn rain.
When you awaken in the morning’s Hush.
I am the swift uplifting rush.
Of quiet birds in circled flight.
I am the soft stars that shine at night.
Do not stand at my grave and cry.
I am not there. I did not die.
Death be not proud.
Happy, happy memories mum.
God bless, love always.
(By Ellen (Nellie) Dalziel – 23rd April 1630)
Please check the date, when Ellen Dalziel lived. You will now understand that death has been mankind’s, greatest tormentor.
Even the Holy Bible mocked death when it asked rhetorically “Death where is thy sting” 1 Corinthians 15:55 “O death where is thy sting’ “O grave where is thy victory”.
How do you as a medical doctor tell a patient that he is about to die. That is part one. How do you then explain to their father, mother, wife, children and relatives that the person you brought is about to die is dying and is dead – Part two.
I know that doctors must help patients understand when they are approaching the end of life. This information influences patients treatment, decisions, and may change how they spend their remaining time.
While certain diseases such as cancer are amenable to prognostic estimates, regarding the time and course of death, the other common causes of mortality in Nigeria – including heart disease, stroke, chronic lung disease, dementia and suspicion of being killed by witchcraft, have more variable trajectories and difficult to predict prognosis.
Patient’s experiences at the end of life are influenced by their expectation about how they will die and the meaning of death. Most people fear how they will die more than death itself. Patients report fears of dying in pain or of suffocation, of loss of control, indignity, isolation and of being a burden to their families.
All of these anxieties may be alleviated with good supportive care provided by attentive group of doctors and care givers.
Death is often regarded by doctors, patients and families as a failure of medical science. This attitude can create or heighten a sense of guilt about the failure to prevent dying. Both the general public and the clinicians are complicit in denying death. Treating the dying persons merely as patients and death as an enemy to be battled terribly in hospitals rather than as an inevitable outcome to be experienced as part of life at home.
Two weeks ago I met a female Professor(name with held) in Federal Medical Centre – Umuahia the husband was very comatose and in oxygen 24/7. Heaven and earth were being moved to ensure he survives – MRI, CT Scan etc. Even the already very expensive antibiotic Rocephine he was on, was changed to a more expensive one that was double the price of Rocephine. We were all focused on the man staying alive. As at the time I met the professor they had spent and accumulated more than 5 million naira in hospital bills and still counting.
Three days later The Man Died (Apologies to Prof Wole Soyinka). We did not prepare our minds for his demise.
Two years ago a colleague of mine a Retired Permanent Secretary had an accident. He was knocked down by a hit and run Keke Napep. He hit his head on the tarmac, and instantly became unconscious. He was first managed in FMC Umiahia and then referred to Neurological Hospital in Enugu, where he was immediately intubated and put on a resuscitator for more than 3 months. He never regained consciousness till he passed on. He accumulated a hospital bill of 24 million.
There are a lot of instances I could cite but for lack of space. Our ability not to let go has resulted in a scenario that approximately 75 to 80% of people in Nigeria die in hospital or long term care facilities. Sometimes this leads to our shopping for the best doctors and institutions at a very high and expensive cost.
Even when the doctors continue to pursue cure of potentially reversible disease, offering comfort and helping the patient and their relatives prepare for death should be foremost considerations.
Patients at the end of life and their families identify a number of elements as important to quality end – of – life care.
Managing pain and other symptoms adequately.
Avoiding inappropriate prolongation of dying.
Preserving dignity.
Preparing for death.
Achieving a sense of control Relieving the burden on others and Strengthening relationships with loved ones.
After death the problem becomes how to notify relations. For over 40 years of my medical practice, this is the part, I had always wished I could plea, like Jesus did in the Bible “O My Father, if it is possible let this cup pass from me” – metaphorically speaking.
But I follow certain guidelines which were enumerated by past medical practitioners, which they tagged suggestions for the delivery of bad news, in the dying patients.
Prepare an appropriate place and time.
Address basic information needs.
Be direct avoid jargon and euphemism.
Allow for silence and emotional ventilation.
Assess and validate patients reactions.
Respond to immediate discomforts and risks.
Listen actively and express empathy
Achieve a common perception of the problem
Reassure about pain relief.
Ensure basic follow up.
There must be unambiguous rapport between the clinicians (doctor, nurses) and the family of a dying patient.
There should be excellent communication including doctor’s willingness to talk about death, timely and clear information, proactive guidance, listening, with empathic responses.
We must practice for the dying person, advance care planning and clear decision making. Including culturally sensitive communication, achieving consensus among family members and an understanding that surrogate decision makers are trying to determine what the patient would have wanted, not what the surrogate would want.
There should be total support for home care, in case the medical personnel decide that the patient is better dying at home. Including orienting family members to the scope and details of family care giving, providing clear direction about how to contact professional caregivers and informing the patients and families of the benefits of home care.
There should be empathy for family emotions and relationships including recognising and validating common positive and negative feelings.
Attention to grief and bereavement including support for anticipatory grief and follow – up with the family after the patient’s death. Always be medically guided
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