One of the most overlooked aspects of medicine at public hospitals across India is the communication of the news of death. Unfortunately, there is nothing in the medical education curriculum about how to tell a patient’s family, friends and attendants that he or she has died. There is little to prepare doctors for the various difficulties they may face in conveying such news. Across the country, the news of death has increasingly led to violence against doctors.
“On my second or third day of residency, I had to declare a death at 5 am on my own,” said Dr Mrunal Awalekar, surgical resident at Government Medical College at Aurangabad. “Nobody told me how to do it. I didn’t know what to say.”
Although declaring a patient dead is a doctor’s medico-legal responsibility, most doctors learn to perform this crucial and tricky task – one that is fraught with uncertainty and emotion – by observation. I asked a dozen doctors like Awalekar who work in public hospitals about what transpires when they break the news of death to the bereaved.
Most doctors are emphatic that when a patient’s condition begins to deteriorate, they update the family at regular intervals and counsel them about the imminent possibility of death, without giving false hope.
Sometimes high-risk cases show up at emergency rooms, such as cases of trauma or that of pregnant women with obstetric emergencies. In such cases, doctors must operate on the patient if they have to have a chance at saving her life. If there is a possibility that the patient might not recover from surgical anaesthesia, the family is counseled before the surgery, and either the patient or the family’s informed consent to perform the procedure is taken.
When a patient is brought dead to a hospital, the family is immediately told that he or she is dead. If a patient collapses in the ward, the doctor on duty begins performing cardiopulmonary resuscitation, commonly known as CPR. CPR is performed behind a screen if possible, so as not to agitate the patient’s attendants.
When all measures fail, the doctor confirms the absence of heart sounds, breath sounds, pupillary reflexes, ECG waves and other signs of life before declaring death.
However, doctors sometimes delay the announcement of death out of a desire to avoid shocking the family and from fear of violent reaction. Awalekar said, “Sometimes, when I am called to a patient’s bedside, he has already passed away. But I won’t declare death immediately. I’ll perform CPR for 15-20 minutes, then declare death.”
Dr Pallawi Priya-Kumar, who worked at Mumbai’s MT Agarwal Municipal Hospital, says, “My seniors would say, ‘Wait for an hour or so, let the relatives feel something is still being done.’ In that time, I might talk to the family and tell them that the patient is sinking. But he would already have passed.” Several other doctors said that they also followed this this practice.
Some families then insist that a patient be moved to an intensive care unit, even if the doctor explains that ICU care will not save the person’s life. What adds to a family’s agitations are the unavailability of ICU beds, shortages of hospital support staff, and being asked by doctors to procure out-of-stock lifesaving drugs at the last minute.
Who tells the family?
“It is one of the paradoxes of medicine: the more junior you are, the more often you have to declare death,” says Jarin Noronha, an oncosurgeon who recently finished training at Mumbai’s Tata Memorial Hospital. The unwelcome task of declaring death almost always falls to a first-year or second-year resident, who is often the only doctor present in the ward or ICU at the time of death. Unless the death occurs before the morning rounds of wards by senior doctors or a patient is a high-profile case, senior doctors are almost never involved.
Doctors at some public hospitals take the initiative themselves to make sure that the family hears the news of death from a doctor with whom they are most comfortable.
Often in Indian hospitals, attendants of other patients tend to gather around and stare at the body, creating awkward situations both for the doctor and the family of the person who has died. The best practice is to ask the relatives to step away from the bed and guide them to a side-room of the ward or ICU, but this is not always followed. Sometimes, families have to make do with receiving the news of death in a corner of a ward or in a corridor, with no place to sit.
If the hospital has security guards and particularly if the doctor is expecting trouble, they may be summoned and asked to stand unobtrusively in the background. Few doctors believe that guards will be of much use in an altercation.
How is the news broken?
The first few times a doctor has to convey death, she may rehearse what she has to say but over time, she develops a stump speech of sorts. “Sometimes, when the situation was tense with 50 angry people waiting outside, I just blurted it out,” says Dr Priya-Kumar.
Most doctors agree that the ideal explanation involves the following: the patient’s diagnosis, how his condition worsened, what efforts were made to save him and finally, some version of “he has died” or “he is no more”.
A sudden, unexpected death after admission comes as a shock to both family and doctor. Dr Arundhati Tilve, assistant professor of obstetrics and gynaecology at Mumbai’s Nair Hospital says: “If a baby dies during labour, there is no way to prepare the family. All you can do is tell them the truth; that we did everything we could but there was no way we could foresee it.”
Disconnecting the ventilator and drawing a sheet over the deceased’s face convey the irreversible finality of death.
What influences the conversation?
“Intrinsically, everyone has a different level of empathy,” said Siddharth Warrier, a neurology resident at Lucknow’s Sanjay Gandhi Post Graduate Institute of Medical Sciences. “I’ve seen some doctors say ‘mar gayaa hai’, disconnect the ventilator and start filling the death certificate.” In such cases, Warrier indicated, the doctor showed no empathy to family members breaking down over the death.
The tone of the doctor’s conversations with the family before death is mirrored in the conversation after death. A doctor may identify the decision-maker of the family, or a potential trouble-maker, and speak to him first.
The average patient at a public hospital is unlikely to understand the intricacies of the progress of disease and of medicine. But Dr Hamza Dalal, who got his Doctor of Medicine in general medicine from Pune’s BJ Medical College, says that it is a mistake to think that a patient’s relatives are not intelligent enough to understand what has gone wrong. “It’s not enough to say ‘he has malaria’,” he said. “They’ve seen people recover from malaria, they need to know what the problem was in this case of malaria.”
Language is another barrier. With medical colleges admitting resident doctors from other states and hospitals admitting patients from other linguistic territories, a colleague or a nurse has to act as interpreter.
Work pressures may affect how much effort is put into the conversation. Dr Anand Karnavat, who has just completed his surgical residency at Jawaharlal Institute of Postgraduate Medical Education and Research said, “If someone expires in the last few hours of a 24-hour shift, sometimes you’re too tired to explain in more than one or two lines.”
The writer has been trained in medicine and holds an MBBS degree.