The book was designed to be practical -“psychology on
the streets”.
I endeavoured to carry through the gist of just a few complex
theories dealing with concepts of grief and depression without actually detailing them.
The purpose is simple.
It is to “empower” Emergency
Medical staff to deal “appropriately” with the acutely dying patient or with
the bereaved relatives. It aims to do this by explaining the need to initially
establish-, and then actively use-, the emotional and cultural context of any
particular death for any particular family.
This will allow for the death to be “appropriate” or "authentic", so
that it might become a positive force later on in the mourning process.
This will also go some way to preventing feelings of
cognitive dissonance for the staff by enriching their interactions with the family and the patient if he is conscious and aware.
There are practical spin-offs to enhancing the
relationship , not least in the area of organ retrieval.
Two new concepts needed to be
internalised.
Firstly. EMS staffers need to realise that death is
the natural and inevitable conclusion to all life, including their own. There
is always, for everyone, a point at which his or her life will end.
This is clearly not the same as saying there are no
‘unnatural deaths’ in a criminal or legal sense. All EMS staffers see their fair share
of criminal deaths.
More importantly though is the idea that death may in
fact be the “natural” or "statistical probable" or simply the “medically
inevitable" outcome of a particular disease or traumatic episode or insult.
There are numerous potentially-fatal physical conditions
for which cures, treatments, procedures or protocols have been developed.
Conditions and syndromes that patients expected to die from 100 years ago, such
as diabetes, are no longer “natural” killers, because for example, insulin has changed the
“medical inevitability” of the progression of the disease; or it has done so within first-world or western-oriented, profit driven health models.
Equally , conditions such as “shock lung”, first seriously
described during the Vietnam War, and now commonly seen as being part of
ARDS/DIC no longer kills fit and otherwise-healthy people who suffer a serious
traumatic insult and who are properly managed during the “Platinum 20 minutes”;
or the “Golden Hour”; or the days and weeks spent in an intensive care unit.
Sometimes though, the traumatic insult is of such a
nature that the “natural inevitability” of death, - i.e. the statistical chance
that the organism will not survive-, far outweighs any impact that any medical interventions could have on the inevitability of death.
So the graph lines of “natural inevitability” and
“medical inevitability” coincide.
The problem for EMS staff is that the interventions,
which have been developed to “prevent” death by prolonging the medical
inevitability, have become the purpose of the intervention.
Because technology and skills and interventions exist to
'save' patients who have a high natural probability of dying (such as a gunshot
wound to the chest), it is assumed that the technology will always work.
It has created the idea that there is always a
medical treatment available, which will swing the odds away from a patient
dying, that the “natural inevitability” will be overcome. This has distorted
the reality of death and the dying process.
Death has become a “differential diagnosis” ranked
somewhere below ARDS/DIC, with renal failure edging it out.
It has also become downgraded in emotional importance
for the staff by becoming the end result of a physiological/technological ‘video’ game.
And if the patient dies, then the staff have only lost
an intellectual game. Buckingham writes, “Death in the acute care setting
represents (only) a technological
failure.”
There are of course very good reasons for these defence
mechanisms, which will be dealt with elsewhere in the text.
Secondly then, a new concept of “acute death” needs to
be introduced.
Assuming that everything possible has been done to
resuscitate the patient, -both in terms of resources and interventions-, but
that his death is still inevitable; then it is necessary to allow the patient
to die with cultural relevance and natural dignity.
To die quietly.
To die with his family in attendance.
Buckingham suggests, “effective Hospice care means that
the patient and the family are inextricably intertwined”.
And just because the
patient has died and the physiological problems are over for the staff, it
certainly does not mean that the totality of care is over.
I would suggest that the acutely-dying-patients’
emotional, spiritual and psychological needs are as important as anything else
during the resuscitation process.
Given that the patient is often unconscious or that the
interventions are aggressive, the emotional needs of the patient should in effect
be transferred to the family.
In the same way that a chronically or terminally ill
patient is treated by having his disease process explained and his “human”
needs met, so too must the “human” needs of the acutely dying patient be met,
in the form of care, support and respect to the family in addition to respect
for the patient.
The needs of the family are always as important as those
of the patient.
This book is designed primarily for EMS personnel but
will equally be of use to other personnel involved in frontline services.
It is necessarily a textbook of sorts and unfortunately quite
didactic in tone.
And its focus is more medical than most similar books.
As such, there are parts of the book that may cause
offence if it is seen as being prescriptive or even manipulative, in particular
the issues of organ retrieval.
Let me say unequivocally that there is no intention to
offend.
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