Wednesday, September 15, 2010

malaysiakini: Good doctors are good communicators... by Dr S

Good doctors are good communicators
Dr S
malaysiakini, Sep 14, 10
I am writing to 'AM" in response to his/her letter Taiping Hospital snuffed out my father's life
Firstly my condolences to you and your family on the loss of your father. I have taken some hours to write this reply to hopefully make you feel a little better by shedding some light on the reasons behind some of the actions by the doctors who treated your father. I would also like to shed some light on possibly what could have been improved on and hopefully relieve some of the negative sentiment towards Malaysian hospitals and doctors despite me not being affiliated to any of them.

My name is Dr S, a Malaysian, and I graduated and currently work in the UK for the National Health Service. I will pitch my letter for everyone including non-medics and try not to use very technical terms or to simplify any that I use. From the story you have related, and my experience working in General Medicine, Old Age Medicine, the Emergency Department, and other critical departments, I gather that your father suffered (in simple words) a large heart attack, and as a result had rapidly progressive heart failure.

Such an occurrence in a 94-year-old is almost always not remedial no matter what is done, especially if the bulk of his heart muscle tissue is no longer functioning due to the heart attack. If at all there was any possibility of active treatment of his heart attack, it would have been early thrombolysis (administration of medication to dissolve the clot that was causing his heart attack) with the hope that the heart muscles that were starved of oxygen were not totally dead, which happens pretty quickly. Thrombolysis is not always possible, as there strict criteria and many contraindications (things that would make him unsuitable for it).

Based on what the doctors at the Taiping hospital told your relatives at the emergency department (that he had a heart attack, and that his heart was weak) and the classical sequence of events on his condition, it seems to me that they conducted the relevant tests, did the relevant examination, and concluded that he had a heart attack and a resultant heart failure very early on. The diagnosis of an acute coronary syndrome is not inaccurate, as it is a broad umbrella of a number of conditions where the heart is/was starved off oxygen, which includes what your dad had - which is likely to have been a heart attack.

In someone who is 94, even if he was quite fit and able otherwise, if it was even a slightly delayed presentation with no chance of busting the clot (thrombolysis), CCU and ICU would not be the right thing to do. ICU in simple words would be for those who need full-time monitoring and treatment for an acute problem that is very likely to be remediable (not the case in your dad unfortunately), and CCU for those who need active constant cardiac monitoring due to the potential need of immediate cardiac intervention usually signaled by cardiac arrhythmias (irregular beating of the heart) or monitoring after recent intervention which could cause arrhythmias (like if your dad was thrombolysed).

Admitting him to a standard ward was thus the most appropriate place for your dad from a medical point of view, and if your dad had the same problem in the UK under the exact same circumstances (with the assumptions I have made) - it is exactly what would have happened. Inotropes is not something I would have given and was not going to be the appropriate treatment for him at any point in time unfortunately. I am guessing that the CCU and ICU option which you were very keen on may have been standard practice in the past when you were practicing hospital general medicine which I assume you no longer do.

Touching on his diet - I don't know what his swallowing ability was like on admission. If his swallowing was assessed and it was thought that it would be safe for him to have a solid diet - I see no contraindications for him to have enjoyed whatever food he wished for during his last days. If he had problems swallowing food safely, then a suitable diet would have needed to be considered further. A heart attack and/or a chest infection on its own or even in combination is not a contraindication for a normal diet.

I see many patients who are 94 or older, and in all cases, it is vital for doctors to make rational decisions on medical management which take into account not just the patients age, but also underlying diseases and pre-hospital quality of life (ie. self caring, self-feeding, self-cooking, mobility, etc). It seems to me that the doctor did tell your sister what your dad was suffering from and that your relatives needed to be informed, which was correct, but perhaps a more polite approach and further explanation on exactly what he had and why it was not reversible, why CCU and ICU was not an option, and why she had to tell your relatives sooner rather than later would have helped clarify things.

Communication is key - and it is something very, very strongly emphasized on in the UK health system and health education, and I think can be improved on significantly in Malaysia. I have had to tell patients relatives on many occasions that their father/mother/brother/sister/friend/son had days/hours to live, what exactly was wrong, what the management plan was, and why it was not curable, and it has always worked in keeping relatives calm, in the know, and making them feel part of the team looking after their loved ones.

A drip being absent in your fathers case is a good sign. If he had a drip with fluids running through, I assure you it would have accelerated his death and you may not have made it in time to see him alive. What could have possibly helped his breathing would be some diuretics to get rid of the excess fluid, however this would only prolong his life very marginally, as his kidneys would have likely been on the verge of not functioning at that point. Moving your father to any other ward during his final moments would not have brought your father back to how he was before he was ill - not even close to how he was.

We try very, very hard not to move elderly patients who are clearly at their final days or moments in life as it disorientates and distresses them and confuses all those looking after them creating room for errors, and does not change the final outcome in any way. An emergency trolley, CPR, and intubation again are out of the question, as it would not have changed the final outcome, and at best it would have given him many broken ribs only to die in pain and possibly choking. I am glad it was not attempted and would have been a serious error in judgment if it did.

The doctors could have however come to your aid sooner, but the aim would have been to explain things to you more clearly and ensure your dad was kept comfortable by means of palliative medication rather than to attempt any heroic measures. I take it that your dad was not very alert/responsive when the doctor arrived hence why they shone the light in his eyes - which is the correct thing to do. That the doctor denied your request for him to be intubated was neither pride nor ego but was likely to have been the correct medical decision, as it would have at the very best made things worse.

Touching on the issue on the time of death, it is acceptable for the doctor to record the time of death to be the time at which he pronounced him dead or the time at which another treating health professional saw him lifeless. Even if there was pretentious resuscitation by the doctor for 20 minutes, if the doctor felt that all this was only stopped at 20:17 and at that moment examined him to find no signs of life - it is correct for him to have recorded the time of death to be 20:17. To give you an example of an unrelated situation, if a nurse finds a patient lifeless at 6am, and calls the doctor to pronounce him dead, the time of death will be 6am even if the nurse thinks the patient had passed away at least five hours before being found.

The doctor can even chose to write down 06:30am if that's when he arrives to see the patient, and he is not confident that the nurse made adequate assessments at 6am to be absolutely sure that the patient was dead at 6am. This is not uncommon especially for deaths through the night when the exact time is often not known.

In your father's case, particularly when he was beginning to be breathless and distressed and was clearly near the end, what should have been initiated was a morphine, midazolam, and hyoscine continuous infusion just under the skin, with doses of each drug dependent on what exactly was the distressing issues. At one of the hospitals where I practiced, we used what is called the Liverpool Care Pathway which is a very good guidance and checklist on the management of patients at their final moments of life (which can be up to days or weeks even).

You could hopefully Google it, and I think it should be widely implemented in Malaysia if not already so. On the issue of a post-mortem, this I'm afraid I cannot comment much on as policies can vary greatly from place to place for different reasons.

Finally it is sad to see many respondents attacking the medical conduct of the doctors involved in this situation as well as attacking the practice of medicine in Malaysia, particularly the government hospitals. I will not make comparisons to the UK health system due to my current position and obligations, but I have to say that Malaysians should thank the government many times over for the standard of healthcare they receive. Some may ask why I am in the UK and have not returned to Malaysia - the reasons are personal, and is unrelated to the quality of Malaysian health care in any way.

I cannot find much fault in the medical care of your father in terms of which ward he was in, what he was allowed to eat, that he did not have a drip with fluids running, was not given inotropes, not intubated, not in CCU or ICU, and not actively resuscitated - which were all the right treatment measures. Again, I emphasize that communication is often key, and poor communication is often the cause of many misunderstandings and unhappiness, and can make a big difference in a patients management.

The most successful doctors and consultants I have come across have not been the smartest and most knowledgeable, but are often the best communicators, and I hope all doctors who are reading this, even if they ignore everything else in my response, just pay a little more attention to this aspect of their practice.


francis ngu said...

Should a short communications course not be part of the undergrad programme, or during intership training ?

Could the strict dichotomy of Arts and Science streams in early high school be contributary to a cold technical orientation among some Malaysian medical professionals ?

Could medical education in Malaysia, be made much more humanistic ?


msforty5 said...

Thanks for sharing & its eye opener on What Ifs for non medical people like me.

Now I know why my late 93yr old grandmother refuses to be hospitalised for a kidney ailment towards the last few weeks of her life. After surviving cancer for 40yrs, she chose to die of Old Age at home peacefully without medical intervention.