Death

One of the things that can make doctors seem a little peculiar in the UK is the constant exposure to illness and death and how that makes their attitudes differ from that of society at large. Here, things are completely different again, and at times completely incongruous.

To me, I go to work every day (7 days a week) and see people dying of conditions that would be curable in the UK. This is partly due to late presentation and lack of good preventive health care, and partly due to our resources (we recently discussed the set up of our burns unit and realised that the budget of the whole hospital paled in comparison to that of a western burns unit). To the locals, they come here because we are their best hope, and a significant number of them have their lives improved or prolonged.

This makes the attitudes to death and dying somewhat different from those at home. Amongst the staff, there is at times an incredibly fatalistic attitude. Sometimes we won't see a patient on the round and just be told they "collapsed" overnight. Death is much more readily accepted, and people are less likely to try and work out what went wrong and more likely to accept it as a result of working with the limitations we have here.

This doesn't fit very well with a case I came across this week. Suffice to say, it involved a child with a non-survivable, but not immediately fatal injury. To survive, the child would have needed specialist surgery, intensive care, huge amounts of blood and a three month hospital admission. The nearest unit in which they would have had a chance is probably in South Africa. Even with that, there would be a significant chance of dying. We made the decision not to do anything painful or distressing to the child and allow them to die. This was met with a lot of resistance from the nursing staff. It seems here that it is culturally very difficult not to give maximal treatment, even when everyone knows it is futile. I have spent a lot of time talking to the mother (with the nurses translating), but was still asked this morning when I was taking the child to the operating theatre. Indeed, the Medical Superintendent tells me we have to be very careful in this situation, as patients who perceive that they have not received the same treatment as others are quick to complain and sometimes sue! We have however stuck to the principles of not doing anything futile and distressing and are keeping the child comfortable.

Things are however sometimes different. We recently had a case with advanced HIV, which was resistant to most treatment regimes, coupled with metastatic cancer. After a long discussion with the patient and family, they died comfortably surrounded by friends and family. I today performed an amputation for gas gangrene in a severely ill gentleman. When I had explained that he might die despite surgery, the first comment from the wife was "should I take him home then?". She seems very accepting of what is going on and almost matter of fact about how ill he is. I'm sure such abrupt news would be met with a much more emotional response in the UK.

Of course, when someone dies, there is the wailing. It is difficult to describe, but there is a noise made by recently bereaved relatives, or occasionally very distressed patients. We encounter it every day, often with groups of relatives leaving the hospital or sat in the grounds. It can be quite distressing to hear, particularly the first few times you hear it, but is clearly the local way of expressing their grief.

Death is perhaps best seen here as something that is a little bit closer than we see it at home. The constant risk of car crashes, falling from trees, snake bites and severe infections (worse in those with HIV) means everyone is exposed, and at risk, every day of their lives. This makes attitudes what they are.