ETHICS
Covid-19:
Dealing with end of life issues By Dr Beth Walker and Dr Volker Hitzeroth, Medicolegal Consultants at Medical Protection Society
S
OUTH AFRICA IS a vast and diverse country with eleven official languages and many different cultures. Medical care is often provided in distant and unfamiliar surroundings, far from a patient’s home and away from the comfort of their loved ones. It is therefore, at times, a challenge to have direct contact with a patient’s family and relatives. The current Covid-19 lockdown and associated isolation measures have added to this difficulty as doctors may also have to face the challenge of breaking bad news to patients’ loved ones remotely over the telephone, rather than face-to-face. BREAKING BAD NEWS Before telephoning, ensure you are adequately prepared and well informed of the relevant clinical facts. Ideally, call from a quiet setting where you will not be disturbed. When communicating via telephone, you should identify the person you are calling and confirm their name and relationship to the patient, as well as the name of the deceased patient. Clarify whether the relative is prepared to have the conversation at this time; are they somewhere they can talk, and do they wish to have someone else with them. If you require the use of a translator, ensure that this is arranged timeously. It is best to introduce a translator to the relative at the beginning of the conversation, clarify their purpose and be aware that translated conversations may take substantially longer and create many opportunities for miscommunication and misunderstandings. Speak clearly, introduce yourself and your role. Begin by exploring what the relative knows about the situation so far. This allows you to gauge their understanding and concerns. Before conveying bad news, try to prepare the relative in a compassionate manner, for example, ‘I’m sorry, I have some serious news to discuss with you’. The tone of your voice becomes even more important when you are unable to use non-verbal communication and have to relay sensitive and complex medical information using a translator. Give the news simply and
18 MAY 2020 | MEDICAL CHRONICLE
honestly with empathy, using silence to allow the relative to react to, and process, each part of your discussion. Avoid using medical jargon or ambiguous terms. If appropriate, you may want to occasionally check that the relative is following the conversation or has any questions. If they are distressed, acknowledge this sensitively and give time and support before carrying on. Before closing the conversation, check whether the relative has any further questions and summarise what they may expect to happen next. Document your conversation clearly in the medical records and try to take a moment for yourself after these discussions; you may also wish to debrief with a colleague. There is no single ‘right’ way to do this; you can only do your best from a place of kindness. GRIEVING FAMILY MEMBERS One of the most distressing aspects of Covid-19 is that, in many cases, family members may be unable to spend time with dying loved ones in hospital or be with them when they take their last breaths. The lockdown, social distancing and selfisolation measures have also significantly altered the usual processes of expressing grief and mourning, including funeral arrangements. This disruption to the usual coping strategies and access to support networks after bereavement, may make grief more intense or harder to process. There are avenues to consider for support. Spiritual care, a key element of palliative care, may provide emotional and spiritual support to patients and loved ones. Relatives can also be signposted to information and support available from appropriate charities. These include the South African Depression and Anxiety Group (SADAG) and Khululeka Grief Support for child and teen grief and bereavement support. SADAG can be contacted on 0800 567 567 or 0800 456 789. Khululeka can be contacted by email at prog.manager@ khululeka.org to make an appointment. The distress that may be experienced by healthcare professionals witnessing
patients dying without family present, and the grief of their loved ones as a result, also cannot be underestimated. Supporting doctors’ psychological wellbeing has never been more important. The MPS Counselling service is available to all its members. Please contact MPS if you would like to access this. Alternatively, many professional societies may have access to further information and help. Similarly, SAMA and SADA may be able to advise or assist. DEATH NOTIFICATION In the current South African context, the provision of a death certificate, as well as funeral and mortuary services are declared an essential service. In the case of deaths from COVID-19, there is a reporting duty to the authorities as is the case with all communicable diseases. In addition, on 8 April 2020 the Minister of Health issued new directions regarding the handling and disposal of the mortal remains of COVID-19 sufferers. All municipalities must identify suitably authorised mortuaries with valid certificates of competence to accommodate COVID-19 patient mortal remains. The stipulations contained in the 2013 ‘Human Remains Regulations’ must also be adhered to . These relate to protective gear and safety measures. The laws and associated regulations governing the notification of a death are: 1. The Births and Deaths Registration Act 51 of 1992 2. The Inquest Act 58 of 1959 3. The National Health Act 61 of 2003. After a patient’s demise, it is a doctor’s duty to: 1. Pronounce the death 2. Report the cause of death 3. State whether the patient died of a natural or unnatural cause. In order to confirm a patient’s death, establish the cause of death and exclude unnatural causes; it is expected that a doctor considers the patient’s history, any appropriate collateral information,
completes an examination of the body, reviews the results of special investigations and peruses any other relevant records. It is always good practice to physically examine the patient’s body prior to pronouncing the death. On rare occasions, this may not be possible. In such a scenario the doctor may pronounce the patient’s death without examining the patient’s body if there existed a prior therapeutic relationship and the doctor is familiar with the patient’s health status and illness profile. However, it is mandatory to always examine a patient’s body if the deceased is not a known patient of the doctor concerned and has not been treated by them in the past, ie if there was no prior therapeutic relationship. If the doctor believes that the patient died of a natural cause they may issue a certificate. On the other hand, if the doctor believes that the patient died of an unnatural cause the doctor may not issue a certificate and must inform a police officer. Unnatural causes of death include: 1. Any death due to a physical or chemical influence, direct or indirect, and/or related complications 2. Any procedure or anesthetic related death 3. Any death, that in the opinion of the doctor, has been the result of an act of commission or omission, which may be criminal in nature 4. Any death that is sudden or unexpected, or unexplained or where the cause of death is not apparent. Please note that it is a criminal offence to submit false information to the authorities. DIRECTIONS ISSUED IN TERMS OF REGULATION 10(1)(a) OF THE REGULATIONS MADE UNDER SECTION 27(2) OF THE DISASTER MANAGEMENT ACT, 2002 (ACT No.57 OF 2002): MEASURES TO ADDRESS, PREVENT AND COMBAT THE SPREAD OF COVID -19, Para 7(1)- 8(5) https://www.gov.za/ documents/disaster-management-act-directionsmeasures-address-prevent-and-combat-spreadcovid-19-8 https://www.gov.za/documents/birthsand-deaths-registration-act https://www.gov.za/ documents/inquests-act-3-jul-1959-0000 https:// www.gov.za/documents/national-health-act
