Death Summary

The patient was a pleasant 72 yo f with a PMHx significant for HTN.  She had initially presented to the clinic for follow-up after several months of being without her anti-hypertensive medication.  She was started on oral medication and dismissed home.  As she was leaving the clinic she began experiencing unilateral weakness on her R side and an inability to talk.  Her family quickly realized something was wrong and brought her back into the hospital.  Her exam was consistent with a dense L sided MCA stroke.  tPA was not given as it has at best questionable science behind it.  Also we have no CT scan or the actual drug itself.  Aspirin was administered rectally and the patient was left to recover in the hospital.  Unfortunately, the patient’s blood pressure became increasingly difficult to control and the patient went on to have a generalized tonic-clonic seizure.  IV Diazepam was given and she had no further seizure-like activity.   Plan of care and prognosis were discussed with family.  Without aggressive treatment of her blood pressure (250/120 and up) with IV medication, imaging to truly identify the magnitude of the lesion and eventually a feeding tube to help with nutrition, then the scope of her disability and chances of her recovery were both grim.  The family elected to keep the patient in the hospital.  While the patient showed no outward evidence of discomfort she continued to decline until she passed away on 17/2/17 at 1700.  She was surrounded by a large cohort of her friends and family.

This is a death summary.  Every individual who passes away in a hospital setting receives one of these.  They are cold and “factual”.  And honestly, the one above has more detail than any others I’ve read or written.  Covering an inpatient hospice service, I’ve gotten kind of used to writing a death summary.  Covering an inpatient stroke service also means I have seen those sorts of devastating strokes before.  They’re horrible, awful, terrible things.  We have little treatment for them.  Our main hope is to prevent them.

And that’s the kicker in Haiti.  Primary prevention of medical illness (i.e. preventing the first stroke or the first heart attack) is incredibly difficult.  In speaking with Dr. Leo after this woman’s passing he was quick to point out that her case should be a beacon to the community for why it is so important to treat tansyon oh.  However, he said that the people will say, “Oh she shouldn’t have crossed *that road today” or blame it on other superstitious things.  Maybe her family was “cursed”.  Maybe she crushed the wrong plant as she was hiking up the mountain to clinic.  Seriously, this will be how they explain her death.  Sidenote, having walked from the road to this poor woman’s house I’m surprised she didn’t have her stroke en route.  It was a very steep climb.

Death means so many things in Haiti.  I’ve seen new moms stare blankly or even with some semblance of relief when I’ve told them their newborn passed away.  This woman had “eaten a lot of salt” and there was nearly a riot in the hospital there were so many people clamoring to display their distress over her passing.  Also, how ironic is the “eaten a lot of salt” metaphor for a person being in their older age?  Especially when diseases related to hypertension are likely one of the, if not the most, common cause of death in that population. 

A small contingent of blan from the clinic attended her funeral.  Her daughter has actually been on staff at the clinic for several years, so the family was part of the clinic family.  I didn’t know what to expect.  I figured there would be a fair amount of wailing and shouting, which there was.  I figured there would be a lot of singing, which there was less than I would have guessed.  I figured there would be a collection passed, which there was not.  And I figured it would be at a church, and this was at her home.  Her grave was dug behind her house.  Apparently you have to be a member of the church in order to have your funeral at the church and to be buried in the cemetery.  I remember from before; death in Haiti is big business.

We stayed in the back so as not to generate a large distraction from the proceedings.  Soon I was surrounded by a puffs of smoke.  A group of older men had gathered behind a wall of her house to smoke cigarettes and drink moonshine.  They were laughing in conversation with each other, and I can only imagine that they were sharing loving stories about the recently departed.  Everyone handles death and grief differently, so I’m not going to question their actions. 

As the ceremony closed, the procession was led by two small children carrying a beautiful wreath.  Pall bearers took their place and the casket was carried past us and they began the descent down the steep, slick path leading to the grave site.  They struggled.  It was narrow and the embankment was steeper still.  Thankfully the casket never fell, but there was a steady rotation of men jumping in to help out.  My interpreter, John, was quick to lend a hand.  He had revealed to me days earlier that his father had passed away in the week before my arrival to the states.  He too had had a stroke.  I can’t even imagine how difficult the entire course of events was for him, but his focus was entirely on the family of this decedent. 

The casket was lowered and covered.  The family returned to sit and receive those who came to pay their respects.  Mwen desole pou ou.  Hugs and tears and hugs and tears.  But there was beauty in the grief that I can’t explain.  And as we began our long hike up the steep mountainside to the road we were able to reflect on just how intimate the event was that we had just attended.  This was a deeply loved woman from the community and we were welcomed as family because they knew we had loved her too.  While she passed under our care, we had shown compassion and had offered all of the treatments available to us.

It goes to show, even when you can’t fix, even when there is a potential for fix but maybe not immediately available, even when you’re delivering a message as grim as the one I had to, if you do the small things with great love then people will find comfort. 

Her body was released to her family for burial at home.  This is Dr. Matt Downen dictating death summary on ……. Thank you.  End dictation.