About to die — The Cliff Edge
The mere mention of death startles most, leaving us uneasy. Imagine what it must be like for those who have to face death almost every day — and not only death but also those left in death’s wake. Shrikant Peters is a medical doctor. For him there is no escaping the throes of death. He describes what it’s like for him to be at ‘the Cliff Edge’.
As doctors we spend much of our time getting to and standing on what I call “The Cliff Edge”. In my mind it looks a lot like the rocky behemoths of the Golden Gate National Park in the Free State, pictured above. I was lucky enough to drive through here, when leaving my community service post in the Cape en route to my first job as a medical officer in Hillbrow, Johannesburg.
Students at all levels, be they med students, registrars or senior registrars, clamour to reach this hallowed high ground, eager to survey the surrounding flatland and save the sorry souls about to plunge off the Cliff Edge to their doom.
If only we knew more, if only we could do more, if only, if only. It’s dramatic, it’s intense, and ultimately — it’s just a little ridiculous. As I found out when I finally got to Joburg and surveyed the flatland of inner-city clinic casualties. There were broken people everywhere; patients and healthcare workers struggling to get through the hours they were forced to spend in these godforsaken places.
Duelling the Grim Reaper
To the average observer public health simply isn’t sexy enough. It’s full of meetings, action plans and agreements. In this way it is the polar opposite of clinical medicine — its action-oriented, headstrong and idealistic younger sibling.
One of my earliest memories of medicine was when my brother and I routinely waited outside the casualty at Edendale Hospital in Pietermaritzburg where my mother worked as a family physician. Through the open window I would see doctors performing CPR on hapless victims, people rushing around with equipment, monitors and drugs.
I marvelled at the sight and the idea that I too could one day be doing the same work — saving lives.
Of course all I could see through that tiny, dirty window into the world of medicine was its drama, its glory — as people were saved from death and given new leases on life. That’s what you see from the outside looking in, or when watching medical dramas on TV, give or take a scandalous romance between a doctor and a nurse, or two.
But by and large most of what happens in hospitals is this. People who are going to die, die. People come in after numerous or sometimes single insults to one or more of their body’s systems. If diagnosis and management fail — the inevitable occurs.
There are tears. There is anguish. And if there are unsettled familial and personal grudges there is complicated anger and grief. Ask me, I’ve worked in Phoenix.
I remember Med Reg, the place to which patients suspected of general medical conditions are referred, being absolutely flooded by family members in mourning, the entire place coming to a standstill to accommodate waves and waves of grief-stricken each night.
Faith & Reason
I have to admit that death was a particularly challenging part of my internship. Of course I knew that people would die but just not at the rate that they did. Internal Medicine was an absolute war zone, the worst block when it came to mortality rates. Kudos to the interns that came before us, in the pre-ARV era.
Life expectancy has been increasing in the country since the rollout occurred in the early 2000s. But the quadruple burden of disease which is often quoted, includes all infectious diseases, lifestyle-related chronic diseases, maternal and child diseases and violent injuries. To these I would most certainly add deaths due to health system inefficiencies.
But what troubled me the most as someone who prays and believes was the scores of families crying and praying at the bedside of medical ward patients every night. Especially distressing for me were the ones who I knew were moments away from certain death, whether or not we had succeeded clinically in diagnosing them.
I believe in prayer. And people want more time with their loved ones. Our whole system as it is is designed to prolong life. But still people die.
The cause of death
What could be made of that fact? Immediate causes of death are so fickle. Someone had forgotten to check this or that result. Someone had misread a referral letter. Someone didn’t do a blood culture or read a blood gas correctly. Was that what the difference was between life and death?
It left me really cold. It was so arbitrary. It was so clinical.
Of course there is never really just one cause of death. At some point during our stay on this planet our respective fates are sealed. If you ask me when that is I would say at conception. Actuaries, far more adept than us medical people, get paid to develop predictive formulae for age and risk of death.
There are major and minor contributors and confounders based on our different perspectives and roles in the health system. Based on what and who we see come through our casualty doors, it doesn’t take much imagination for a medical person to understand that all of these factors play a role in predicting your life expectancy: the circumstances of your conception and birth, your home environment, the quality of food and water you have access to, your level of education, your occupation, your coping mechanisms and your social support structure. All of these will change the distance you have left to get to the Cliff Edge.
However as doctors we will unfortunately always find ourselves at that Cliff Edge —waiting to catch everyone who falls over. And it is a mind-boggling place to remain. Stressful, rewarding, demanding, incapacitating and at times — beautiful.
Instead of fighting a neverending battle it is sometimes important to examine where we are standing. Realise that there is a cliff, that the edge is set by a combination of natural lifespan and a country’s access to resources. And that an integral part of our work is to actually help people over it in a manner which affirms their life and dignity.
Extending the Cliff Edge is obviously possible. But this is a venture which we require help with from healthcare advocates at all levels and which requires vastly different tools than ours to take on the system.
Of course all of this is easy to say when you’re not functioning as a clinician but it is important to sometimes sit back and ponder the absurdity of our calling. At least it might help us enjoy the view, from way up over there.
To see some of the great work being done by palliative care practitioners in South Africa, visit: https://www.abundantlifevic.org/
Source: The Public Health Pariah