There is only one end to life

BID. The chief complaint according to the whiteboard is BID. But I cannot figure out what it means. I find these abbreviations confusing, but I am learning. So far I have learned that PVB means paravaginal bleeding. I was quite impressed when I saw the familiar abbreviation IVF on that chart. I did not know they did in vitro fertilizations in Botswana. They seemed to be doing a lot, though, even in men. Of course IVF was short for intravenous fluids. But BID, what could that mean?

– Brought in dead! exclaimed one of the doctors. BID means brought in dead. In the US they say DOA, dead on arrival, what do you say in Sweden when people are brought in dead?

– I don’t know. I answer hesitantly, trying to remember. When I come to think of it, I have not seen that many people who were brought in dead. A few traffic accident victims and completed suicides who were pronounced dead by a prehospital doctor or even a paramedic if the injuries were obviously fatal. Mors would be the chief complaint used in those cases. I always found it a bit absurd, since mors is a perky word for hello in Swedish and the only chief complaint in Latin. As if death would be less frightening in Latin. The other doctor has already lost interest in my mumbling when I come to the conclusion that mors would be the Swedish equivalent of BID.

After several days, and several BIDs, it suddenly dawns on me: Asystole! That is what we call people who are brought in dead in Sweden. Of course we would never admit that they are dead. Even if they are 85 years old and suffer from multiple chronic illnesses when they die in the comfort of their own home. The paramedics still perform advanced CPR and even though they fail, we try again in the resuscitation room. And when we finally give up, we feel that we have failed to save the patient.

In Botswana people in general seem to think that it is the illness that kills the patient, not the inadequate interventions by doctors and other health care professionals. They are not surprised or upset by the fact that when you are seriously ill, you might die.

In Sweden, doctors are expected to save lives. Or at least prolong them. It is barely a matter of discussion. We find it provoking if patients or their families turn down treatment that, according to evidence based studies, will prolong their life. I think that is why we often avoid these discussions. We are however obliged to discuss treatment restrictions with the patient and the next of kin, so when we think it is obvious that the patient is dying we tell them and their family: You know you are really sick, so if your heart stops, we won’t try to start it again.

Sometimes the patient or the family will ask why and we will tangle ourselves up in an explanation about how they will only get rib fractures from the chest compressions and that they might end up in the intensive care unit and that we do not think the resuscitation will be successful anyway. This kind of reasoning inevitably enforces the impression that patients will live if doctors decide that they should.

Since more or less all unwitnessed out-of-hospital cardiac arrests in chronically ill people are impossible to resuscitate, the outcome will be the same regardless of whether the patient is brought in as a high priority case of asystole or as a low priority case of mors. We doctors have come to believe that the former is better for the next of kin, so they can rest assured that they did everything possible to save their loved one. Maybe that holds true for some people, in which case we should probably continue doing it. But for some elderly people, who are often wise enough to realize that they are at the end of life, being allowed to accept death as a natural part of life might be the best option. The question is how we as health care professionals would respond to the old man who held his wife’s hand when she died and then called the primary care physician to come and pronounce her dead. Does that really sound like the natural thing to do or should we notify the police?