What Happens When We Die
Insights from the Accident and Emergency Department
Interview by Michelle Chung
Hospital staff play one of the most important roles in our lives which ironically, will tend to be when we are dying. For many of us, our last moments will be surrounded by nurses and doctors who will be making decisions about how to let us die most comfortably. They will listen to and look at our bodies closely to see if there are signs of life and if so, whether it is worth reviving. And if we take that last breath, they will be the first to tell our closest family and friends.
With this great responsibility on their shoulders and a continuous flow of work in a high pressure environment, hospital staff are still expected to deliver such sensitive information to our family and friends and to keep performing on the job. Doctor Amanda Mitsios (pseudonym) is a senior registrar in an Accident and Emergency department based in the Midlands who has worked with the dying and dead on a regular basis for nearly 20 years. Having certified many deaths in her life, we are curious to know how Amanda sees her role in our deaths and whether with her experience, she has developed beliefs on the role of fate, the connection between the mind, body and soul and the purpose of life itself.
It’s been a particular tough year for the NHS and the many NHS workers who have worked closely with COVID patients. How have you and your colleagues coped with managing patient care and the additional support for their families?
To be brutally frank, the support for families has not been as good as it could be because we are not letting them into the hospital. From a family's point of view, it's much worse at the moment. Instead, we are trying to call them as much as we can. Those conversations are really tricky, telling people over the phone that their family members are going to die or have died. It’s not something that we really ever used to do.
Most families are pretty good about it because it's a global thing at the moment. Everyone is quite accepting of the fact that we are all in the same boat. The whole country seems to have the same policy with regards to visiting. That being said, when patients are clearly within the last hours of life, we always endeavour to get loved ones to their side.
What's the typical support or communication that you are expected to give patients?
For example, if I was working in resus (resuscitation area) and someone came in who was desperately sick, my first aim would always be to get the patient on the phone to their loved one if that was at all possible.
Failing that, I would aim to talk to a family member before the patient had actually died so that I could pre-warn them. Rarely, a patient will come in and die within a very short space of time and so we are unable to have any preliminary conversations with family members.
Typically if a patient was in resus, we would have two to three conversations with the family before their relative moves onto a ward.
That in itself can be difficult because resus can have up to 12 desperately sick patients at a time, and trying to have those conversations with all of those relatives whilst you're doing everything else is pretty challenging. The resus room is very, very noisy, with multiple interruptions, buzzers and alarms, and sometimes it can be difficult to concentrate on the conversation you're having.
Do you remember the first time you told a family that a loved one had died?
Unfortunately, no is the answer, because I’ve done it so many times.
Typically, a junior doctor will certify many patients [as having died] before they break any bad news on their own. They will initially accompany more senior staff before doing it themselves. We also get heavily coached in how to break bad news in medical school, and then in every post graduate exam thereafter. Consequently, the individual events tend to blur together.
The unorthodox ones stand out: the time that I realised a relative was filming me whilst I was certifying their loved one; the time that a mother knew just by the look in my eyes without me saying a word; the time that police had to be called because the death would cause such shockwaves in the community; any paediatric death.
It can be unsettling for us as clinicians when things don’t go to plan, because delivering what is often the worst imaginable news is stressful. We have no idea how that conversation is going to go.
What are the considerations that you have to think about?
First of all, you have to confirm that you're delivering the right bad news to the right person. You also want to think about where you're delivering the bad news - that it's a private room where you're not going to be disturbed.
Then you have to confirm what they know. I get them to talk them through briefly what's happened pre-hospital. I usually consolidate the information that they have given me and then continue on with information about what has happened since their relative arrived in A&E. I try to be brief and clear. Everyone is aware that it is rarely good news if you are taken to a room beside resus, and then the somber faced doctor comes in with a nurse for a chat.
It's never easy and it doesn't actually get any easier to be honest. You’re never sure of how anyone is going to react. I never really feel as if the conversations went well. It’s difficult to tell the relatives that you have failed. You can feel quite responsible in a way and that adds to the questioning around “could I have, should I have, what if I had done X, Y, and Z?” Even though you know that you did do everything and that you did do your best.
To what extent do you feel like you have control of somebody's ability to live? How do you manage that responsibility and avoid that sense of feeling like a failure?
As an A&E doctor we are trained to cut open someone's chest, in a stabbing, for example, to try to get blood out from around the heart. We also have to be prepared to surgically deliver the baby if a heavily pregnant woman goes into cardiac arrest - this can be potentially life saving for both mother and baby. However, these sorts of procedures often have incredibly low success rates. You’re not really in control of a person's destiny if they've been stabbed in the heart, you know? No matter what you do, you're not going to reverse time and fix that.
Whether I feel like I could help them to live or die, that doesn't really get any easier. That's the thing that you're mostly ruminating about when you go home. You're worrying about “oh gosh, did I do everything? Did I miss something?” You can pour over every minuscule aspect. It gets easier as you get more experienced to acknowledge that you're only a tiny part in that patient's journey. They could have fallen down a full flight of stairs, overdosed on sedatives or their chest infection happened to the patient a long time before I got involved in their care.
You just have to have faith that you and your team have done your best with the knowledge and the skills you have. With the stars aligned in a different way on a different day, there might have been a different outcome? Who knows. All I can do is strive to keep learning and reflecting.
We’re hearing a lot in the news about ‘Do Not Attempt Resuscitation Orders’ (DNACPRs). Do you have any experience with those?
Yes, I do. I think it’s important to clarify that DNACPR relates to the specific act of CPR. We are almost always still actively and fully treating patients, with the hope that they will make a complete recovery from whatever has brought them into hospital. It quite simply means that we won’t do chest compressions.
The act of CPR is a very aggressive, painful and invasive procedure, and not one that I would particularly want to experience. We frequently feel patients’ ribs break as we do chest compressions and we often have to use a drill to put a metal needle into the patient’s leg or shoulder bones in order to give them the necessary emergency drugs. During the process of inflating their lungs with oxygen, the stomach will often also become inflated causing them to vomit and breathe it in. To mitigate against that, we will put a large tube down their windpipe. All of this happens whilst they are in the process of dying and we have no real idea how much of it they might be aware of.
Also the average survival rate if you have a cardiac arrest out of hospital is only 12% which means up to 88% of people will die. If you have a cardiac arrest in the hospital even with all of the necessary people and equipment right there, up to 75% of patients will still die. If there are any underlying health or frailty concerns, the recovery from a cardiac arrest will be prolonged and uncomfortable. Some patients do not survive to discharge and most survivors won’t return to the same level of health or independence that they had before.
With all of that being said, I am definitely sometimes more in favour of giving people a pleasant death than trying to force them to stay alive. Signing a ‘DNACPR’ is quite often one of the kindest, most humane things that I can do for some of my patients.
How do you certify death and what happens to the body when you are dying?
There is a specific process to certify death. You look for any respiratory effort, you listen to the chest for three minutes for heart or breath sounds, you feel for central pulses and examine for any pupillary reaction.
The dying process often starts before death and it continues after you die. When people are desperately sick and we take their bloods, we can see that they are dying - their blood becomes hypoxic* and acidotic*. We see a lot of electrolyte and chemical changes that tell us the tissues are in the process of dying.
When patients are dying, we can also very clearly see their conscious level change. It can reach a point where the brain has died before the heart has stopped, and in those instances we follow a step-wise, two doctor process and certify brain death.
Death is a conceptual thing and you can talk about it in many ways. Are we talking about the death of the body, the death of the brain, or the soul?
Do you have an opinion or belief of the mind or soul dying or passing on at the point of death?
I do think and hope that in the patient’s semi-conscious state, they can be aware of presences, like the presence of loved ones. And I think the soul is still there with the patient until they have actually died. Then thereafter, I don't know if it floats off or if it just stops.
I’m not religious but I believe in a higher power that we don't understand. I do find it difficult to try to imagine what would be manifested in any afterlife because I believe our minds and our souls are fundamentally linked to the neurological electro-chemical workings of the brain.
And if the brain is not doing that anymore, then I don’t know how any ‘soul’ would function. It is also difficult when you have looked after people during the slow decline with dementia. You look at them and search for the person they used to be. Are they still there despite the obvious impairment in their brain activity?. But when you're dreaming, you have a sense of yourself but there isn't actually any physical manifestation there. Our soul is active, but our bodies are not. There are so many things that we don't know. Maybe there is capacity for an afterlife.
How do you think your work in A&E has influenced the way you think about life?
Dealing with death so often, I feel the need to enjoy the present and make an effort to really notice the beauty around us everyday. Often when I'm in my garden with my family, I just pinch myself at how blessed we are. I really feel like this is heaven now. You have to just be grateful for the moments where you're healthy and happy and that you're still alive. Life is such a precious gift.
One of my older patients the other day was telling me their life story and that they had lost a child. He just said that everyone will have loss to cope with at some point in their lives. It will happen to everyone and so we really have to be grateful for every minute.
Is there any piece of advice or observation you could share from your work, which could offer some sort of comfort or solace to people who have lost someone close to them?
I think the majority of the time and probably even in a traumatic death, in the actual moment of the person dying, when the heart stops and the brain is no longer being perfused*. I hope that moment is not painful. When the brain is switching off, you become unaware. When people are in a more prolonged phase of dying, we make the process as pain-free and comfortable as possible with different medications that can alleviate the symptoms of dying.
I hope that is comforting to people, that death itself is not distressing.
Glossary
Hypoxic: Low oxygen levels in the body
Acidotic: High acidity in body fluids
Perfusion: The passage of blood or fluid through a blood vessel or other channel in the organ or tissue