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As of January 2019, we will no longer be sending out the doctorportal email newsletter. The final issue of this newsletter will be distributed on 13 December 2018. Articles from this issue will be available to view online until 31 December 2018.

Should we teach death in schools?

 

A proposal from the Queensland branch of the AMA might have schools slotting death lessons into the timetable in between Maths and English.

AMA Queensland Chair of General Practice Dr Richard Kidd says in a rapidly ageing society, educators should be demystifying the processes of ageing and dying.

“Young people need to be educated about medical, legal and other issues that surround ageing and dying so they are capable of making informed choices when the time comes,” Dr Kidd says.

“More than any other generation, they will need to understand advance care plans where their loved ones decide how they want care to be delivered at the end of their lives. Young people also need to know how to make a will.”

Dr Kidd says he has seen cases of young adults getting terrible injuries playing sport, and that it would have been a huge help to families and doctors if they’d known how the loved one had wanted to be cared for in their final days.

“I’ve seen people as young as 21 being thrust into the role of power of attorney,” he says, adding that their lack of knowledge makes for a steep learning curve in how to act in the best interests of their loved ones while remaining within the law.

He says that “death lessons” could incorporate the legal aspects of what mental and physical capacity means, how to draw up a will and an advance care plan, and the biological processes of dying and death.

Knowledge around death and advance care plans could facilitate people dying at home rather than in a hospital, Dr Kidd says. Although the vast majority of people say that they would prefer to die at home, only 15% do, he notes.

“Many more people could die at home if there had only been a bit of preparation,” he adds.

He says that in many families, death is a taboo subject that only gets discussed once it’s too late.

The proposal has been put to the Queensland  government and has got backing from Palliative Care Queensland, whose CEO Shyla Mills says learning about death at school would make young people more resilient about loss, ageing, dying and grief.

“While there is pressure on educators to add more material into the school curriculum, death is our only 100% guarantee in life and the effects of our ageing population will be felt most by those at school today,” she comments.

Diagnosing death: not as easy as you might think

 

A new Viewpoint in the New England Journal of Medicine this week looks at the thorny question of how we distinguish the living from the dead. As the author, bioethicist Dr Robert Truog, points out, being able to clearly make this distinction is an essential function of any society, determining who can be buried, whose wills can be executed, when people can be taken off a ventilator or when their organs can be donated. At first blush, the question of knowing whether someone is alive or dead may seem relatively straightforward – but there’s a surprising amount of disagreement and variation around how death is actually defined.

Take the recent case of Jahi McMath, a 13-year-old girl from California. In 2013, after undergoing a complex tonsillectomy, she experienced a massive haemorrhage which left her with severe, irreversible brain damage. Her doctors proclaimed her brain dead and notified a transplant donor organisation. But her parents didn’t agree, and went to court to oblige Jahi’s doctors to keep her on a ventilator. They argued that whatever the state of her brain, Jahi’s still beating heart meant that she was still alive.

Eventually the courts let Jahi’s parents remove her from the hospital, which issued a death certificate. Jahi was moved to New Jersey whose laws prohibit clinicians from declaring death by neurological criteria if this violates the religious beliefs of the patient. The upshot is that Jahi is legally dead in California, and legally living in New Jersey. She is kept biologically alive with a ventilator, feeding tubes and hormone supplementation, and her body continues to develop. Now aged 17, Jahi has  passed through puberty since her brain injury.

Jahi’s case is rare, but certainly not unprecedented. She is one of what are known as “beating heart cadavers” – people who, after a devastating brain injury, no longer have any brain function, although their hearts can be kept beating with medical intervention. Some of these beating heart cadavers can live on for months or years or, in one case, for two decades.

In most jurisdictions, beating heart cadavers are considered dead for legal purposes. But definitions of brain death vary from country to country and, as can be seen in the Jahi McMath case, even from state to state within a country.

In the UK, for instance, brain death can be declared when there is no activity in the brain stem, even though there could still be activity in the cortex. We are stricter in Australia, where brain death can only be declared when the whole brain is dead. But Australian law leaves it up to the doctors to determine “the creation and prescription of techniques of diagnosis” of death, without further defining how that may be done.

This vagueness has led to controversy in the past. In 2013, Melbourne-based bioethicist Professor Nicholas Tonti-Filippini claimed that patients in ICU were being declared brain dead and having their organs harvested even though they had not been properly found to be brain dead.

“They are diagnosing brain death while there is still some midbrain function. They say. ‘So what?’, because the person is not conscious.” he told Fairfax Media.

But the claims were strongly denied by the Australian and New Zealand Intensive Care Society, which claimed its brain death criteria were “an exemplar of rigour”.

Dr Truog, in his Viewpoint, says the problem with definitions of death stems at least in part from a variance in the way things are defined legally and biologically. Legal definitions are typically defined by “bright lines”, whereas biology tends to be continuous. He gives the example of how people acquire a completely new legal status in society on their 18th birthday, despite the fact that they are biologically and psychologically barely any different from the day before.

Death, he suggests, may be like that. There may be a legal point at which one is dead, but death itself exists on a continuous biological spectrum. There may be some people who have barely any more brain function than Jahi McMath, but who are considered by most jurisdictions as alive. And these patients may be able to live for many years.

The legal definition of death, like so many other legal definitions, is a social construction, Dr Truog says, “based on biological reality but not completely defined by it.”

Jahi McMath’s case remains relatively rare, which prompts Dr Truog to wonder why there aren’t more cases like her. The answer, he says, is that diagnosis of brain death acts as a self-fulfilling prophecy.

“In almost all cases, the diagnosis of brain death is quickly followed by removal of the ventilator or by organ donation, which invariably leads to cardiorespiratory death,” he writes.

You can access the full Viewpoint here.

Is it OK to attend your patients’ funerals?

 

She’s a long-time patient, and over the years, your professional relationship has developed a certain personal dimension. You treat her in her decline, refer her to palliative care and she passes away in a hospice. Should you attend her funeral? Or does this cross a professional line? It’s a delicate question that hasn’t been much examined in the medical literature.

In a recent opinion piece, a Melbourne-based anaesthetist looked back at her management of a patient with pancreatic cancer, who she helped “navigate the tortuous terrain of mortal illness”. Dr Katrina Barber found herself a first-hand witness to the “raw emotion that spills over with the coming of death”.

“I wondered whether it would be appropriate to attend the funeral of that patient. Even after the worst had happened, I didn’t have the answer.”

Although Dr Barber ultimately did go to the funeral, she points out that “the right course of action for one doctor may not be the correct course for another.”

She notes that while the presence of a doctor may offer comfort to the patient’s family, it could also “stir up problems rather than bring solace”. It could invite anger or recriminations from the family who may blame the clinician for the loss of the patient’s life. There may also be wider-ranging implications concerning patient confidentiality.

Given that this is a dilemma likely to be faced by most doctors, surprisingly little research has been done on doctors attending patient funerals. But one of the only recent studies on the subject is Australian. Researchers from the University of Adelaide carried out an anonymous survey of 437 doctors and found that most had attended at least one patient funeral. GPs were the most likely to have attended a funeral (71%), while surgeons (52%) and ICU specialists (22%) were the least likely.

Female doctors were more likely to have attended a patient funeral, and they were also more likely to do so out of grief for the patient’s death rather than a sense of obligation. Women were also more open to crying at a funeral and discussing going to funerals with their colleagues. Young male doctors were the least likely to attend.

Study co-author Associate Professor Greg Crawford, who works in palliative medicine, said the benefits of attending a patient funeral may be twofold: “It’s a practice that may help physicians deal with their emotions after a patient dies, and in turn it can also be of comfort for the patient’s family,” he said.

But he said there were differing views in medicine about its acceptability, with some doctors feeling it to be unprofessional and other feeling that their colleagues might disapprove of them.

“The medical community should ask itself whether funeral attendance needs to – and can – be addressed more openly, whether death and dying should be discussed more candidly among health professionals, and what effects these discussions may have on job satisfaction and on the mental health of medical practitioners,” the study authors wrote.

Six tips for coping with patient death

 

A couple of years ago, a photo of a doctor outside a hospital crying after losing his 19-year-old patient hit a nerve, and ended up being shared hundreds of thousands of times on social media. The photo captured one raw reality of working in medicine, which is that patients die, and it’s not always possible to respond with the stoicism that is expected of doctors.

Dealing with death is a fundamental part of being a doctor, and most doctors intuitively understand the need in professional life for a balance between compassion and maintaining a certain emotional distance.

But sometimes they will find themselves profoundly affected by a death, possibly of a patient they had known for a long time or with whom they had a special rapport. In these circumstances, the patient death can provoke feelings of helplessness, guilt or failure.

An added stress for doctors in some cases may be the worry of a complaint or even legal action from the family of the deceased.

Research seems to suggest that doctors are not especially good at coping with feelings of grief about patient death, nor do they receive adequate training for this. More worrying still, there is evidence that poor coping with patient death affects doctors’ ability to treat their other patients.

A recent study of 20 Canadian oncologists reported that more than half struggled with feelings of failure and self-doubt after a patient death, and felt their grief could affect their treatment decisions with subsequent patients.

Losing patients also affected their ability to talk about end-of-life issues with patients and families. Half of the participants reported distancing themselves from their patients as the patient got closer to dying.

The study suggested that grief in medicine is still considered shameful and unprofessional, and that even when doctors struggle with their feelings of grief, their instinct is to hide them from their colleagues.

Here are some tips to dealing with the death of a patient:

  • Be completely honest with the patient’s family, and with yourself, about what’s happened;
  • Convey empathy to the family and share their feelings of loss, if they are open to it;
  • Discuss the case with your colleagues;
  • See your GP if you feel a patient death is unduly affecting your professional or domestic life;
  • Accept that negative outcomes will happen in your professional life;
  • Accept that grieving is natural, even in the context of the doctor-patient relationship.

Source: BMJ

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