Surrinder Singh

Discussing the finer nuances surrounding this very sensitive subject can be emotionally challenging on many levels. And everybody’s experience in dealing with death and dying is unique.

Based on this, I was encouraged by many I consider close to share my story with a wider audience. I began this narrative as a cathartic process seeing as many individuals I’ve known have died within the last few years.

Of all life’s experiences, death, grief or the loss of a loved one are considered one of the most traumatic events for any individual.

Having been raised in the Western world, I was often encouraged to ‘deny’ the concept of death and would maintain a stoical attitude about it. 

It largely remained “in absentia” from my consciousness, considering it an incredibly taboo subject. It is certainly not part of normal everyday conversation. I had to delve deep into my metacognition to offer an honest opinion.

When I first experienced grief and loss myself, the limbic system in my brain governing emotional responses went into overdrive mode. I couldn’t even begin to envisage the consequences lying ahead of me.

Despite the indescribable feeling that the death of loved ones has elicited within me in the past, I have had to acknowledge that death is a universal experience.

In terms of human suffering, dealing with death and loss can invoke the most unpredictable emotions within us. And depending on our internal mechanisms, whether learnt or innate, many of us cope with loss better than others. 

Macabre images can be conjured in our heads, evoking raw sentiments and are painful to contain.

In my personal life, I have experienced the loss of many loved ones through the pathophysiological processes of old age, murder, and suicide, among my friends and family.

As I get older, I have learnt that more people have died. Therefore, death, dying, and loss are important topics that should be broached frankly and openly. Perhaps even more so, given the current situation we are all facing worldwide regarding escalating mortality with the pandemic, war-torn conflict or otherwise.

Like many, I have even thought about my own death as much as I do not want to. Those who know me will have a tacit understanding that I would like my body donated for medical education or similarly following my death.

After all, I was privileged to learn about disease processes throughout six years at university, and I feel the favour should be repaid to future doctors or scientists.

Looking Back On Life’s Lived Experiences

From a medical career perspective, I have dealt with death, loss, and grief for over a quarter of a century. I have even been accused of over-intellectualising such a subject. 

And as a doctor who specialised in emergency medicine, death and loss have occurred on innumerable occasions at work. However, I have been affected by death in my personal life, which has had psychological effects I often find hard to convey.

For example, I had to face the sudden loss of my father, who suddenly died in my arms when I was a teenager through an acute myocardial insult. 

At the age of 17, I then witnessed my first post-mortem in a hospital mortuary during a high school work experience placement that prepared me for medical school.

Subsequently, I learned about human anatomy on dismembered cadavers during my years at medical school. Remembering the complex three-dimensional topography of a human’s structure was undoubtedly easier on actual wet specimens than referring to dry textbooks – the so-called ‘inexplicable curriculum’.

Witnessing autopsies also provided invaluable insight into the medico-legal implications surrounding the dead and appreciation of the role of a pathologist and a coroner.

In the dissecting room and mortuary at medical school, we were trained to remain focused but professionally distant at the same time to prevent ourselves from crumbling emotionally.

I quote Dr Giovanni Morgagni, the famous Italian physician who originally defined the theoretical basis of anatomical pathology in human disease. This is a standard inscription on the walls of many autopsy laboratories around the world:

“Taceant colloquia. Effugiat risus. Hic locus est ubi mors gaudet succurrere vitae”

“Let conversation cease. Let laughter flee. This is the place where death delights in helping the living.

In other words, research and development into studying the dead will ultimately aid those still alive on an academic level.

The Reality of Death, Loss and Grief At Work

Having worked in countless hospitals, particularly emergency departments, death in this environment can have several disadvantages. They often occur entirely differently from those elsewhere.

First, they occur more frequently than anywhere in a hospital and nearly always arrive from the community. The staff involved will have had nil previous professional relationships with the patient, nor will there be any further connection with any grieving relatives.

Over the years, it is too easy to become desensitised as the individual who has died before you is a complete stranger.

Deaths in emergency departments also present in various circumstances and from diverse racial, cultural, and social backgrounds. They may be dead on arrival or in extremis, And despite valiant time-critical resuscitative efforts, their chance of survival is minimal.

Deaths here are often sudden or unexpected.  There may be a history of severe trauma, violence or suicide deemed incompatible with life from the outset.  Any friends or relatives will not have had sufficient time to anticipate or prepare for such an event.

Emergency departments are notoriously loud and chaotic. And due to the chronic shortage of private beds in a quiet ward, the dying cannot be transferred elsewhere for hours.

As a result, the dying and their relatives remain separated from living patients by ‘curtain-thin’ walls, depriving them of dignity and privacy. However, one has to try one’s best as there is no alternative.

Semi-trained staff may find caring for the dying in such an environment physically and mentally challenging, especially when patients still alive must be attended to simultaneously.

The benefits of thorough de-briefing amongst all staff involved and referral to counselling services, if appropriate, speak for themselves.

Breaking bad news in this situation is undeniably one of an emergency doctor’s most stressful tasks. Relaying life-changing information never gets easier, as every situation is unique. Due to time constraints and sheer workload, encounters with relatives can often feel rushed. 

Emergency workers will have little time to prepare before talking to relatives. Even though the patient’s outcome could not have been changed, they can still harbour feelings of guilt and helplessness if the individual who died was for aggressive resuscitation. Conversely, the scenario is much easier to deal with if the patient was for comfort measures only or was palliative.

In any case, it is extremely important how bad news is delivered. It shapes the entire outcome of the healthcare experience for any remaining loved ones from that point onwards.

As a person relating the information, I have encountered the most unpredictable reactions when delivering unpleasant news. Despite maintaining one’s sangfroid, discussions can become tense and heated as grieving relatives come to terms with the sudden loss.  

Hysterical behaviour is typical and perfectly acceptable as an initial and natural response. Languages of distress are also heavily culture-bound.

Dealing With Death And Loss – The Most Publicised Model

Throughout my medical career, the framework regarding death and grief pioneered by the Swiss American Psychiatrist Elisabeth-Kübler Ross model (1969) is the most studied.

Based on the cognitive map of a patient coming to term with a terminal illness, it describes five discrete stages:

• Denial – Characterised by numbness, shock, and disbelief. Life, as you know it, has suddenly changed and makes no sense.
  
• Anger – The “Why me?”, “Life is not fair” and “It’s just incomprehensible” are profound statements one may say to oneself. Those with a religious predisposition may question why the deity or ‘body’ they worship has not protected them. They may even blame their loved one was sacrificed. Though we are often told to suppress this emotion,  it is natural. Given time, this will dissipate and facilitate the healing process.
  
• Bargaining – The process of self-negotiation, where you are consumed by the “what if I had only….?” questions are prolific.
  
• Depression – Again, this is a commonly accepted stage when coping with any form of loss. It is not uncommon to have any combination of feelings, such as numbness and hopelessness. Our emotions can become so intense that we may want to withdraw from you or those around us. Facing reality and the world is perhaps too overwhelming.
  
• Acceptance – The process of growing and evolving how you define your ‘new reality’. Your emotions begin to stabilise during this adjustment period. You will gradually have better days, which will hopefully outweigh all the bad ones.

Since this model was introduced, it has been challenged and criticised. Subsequent studies have defined the narrative of grieving as non-sequential, where the journey of loss may not follow a linear pattern. Many individuals experience these stages in any order. 

Moreover, they could be more accurately described as ‘states’ of mind rather than a series of logical steps.

This empirical research was also modelled on death in the elderly from natural causes. Grieving for a child who has died suddenly will follow a different trajectory altogether. As will the demise of a spouse or grandparent. 

Regardless, I still believe this landmark model carries significant weight. It can be extended to other adverse life events other than death and dying.

It may explain our thought processes when coping with any significant life event. It could be a departure from a job you once loved, exam failure, a relationship breakdown, abuse in any context, the loss of a pet, learning to live with a disability or coming to terms with being diagnosed with terminal cancer.

The list is endless.

I have experienced many of these in one form or another. More recently, I have been slowly learning how to cope with long COVID-19 syndrome.

Though I don’t wallow in self-pity, I have had to make significant adjustments to my life.

My Thoughts Now Turn To You

As a reader, you may be left with a bittersweet mood or in a negative headspace as I have taken you on my short personal journey. However, this was certainly not my intention.

Unfortunately, death is inevitable and occurs every second, even whilst you have been reading.

In my personal life, when it comes to the loss of loved ones I have known on a more meaningful level, I have often found it impossible to convey my emptiness at times.

If you have ever grieved like me, you will definitely empathise with how awful it can be.

Like a form of PTSD, the concept of ‘survivor’s guilt‘ can be incredibly hard to live with. Allowing yourself however long it takes to come to terms with loss and validating your feelings through self-forgiveness are vital. This is how you emerge even more resilient.

Shared Support and Standing Strong

In the act of respecting and preserving anonymity, several individuals have reached out to me from all corners of the globe. Like they have been there for me, I have also been there for them as an informal counsellor.

Many of them have dealt with or are currently having to face death, grief, loss, or pain in multiple modalities. Their issues are at various stages of resolution based on the grieving model described above.

After reading, they will hopefully learn they are not alone and will seek solace in whomever they trust.  I dedicate this to any readers like yourself or those you know who are coming to terms with loss or grief in any capacity.

That was the very reason for writing this.

Finally…

‘In memoriam’, I pay ultimate respect to my deceased parents, who are not physically present in this world right now. Therefore, I can share my thoughts with them as I have with you.

As part of their Sikh faith, their bodies were washed as part of their last sacred rites with the very hands that I have been typing.

They were both cremated in my presence. I then scattered their ashes into fresh running water near their place of death. Again, this is custom as part of a conclusion to the funeral, known as ‘Antam Sanskaar‘.

From there, they began their journey to the afterlife, wherever that may lie. Though I miss my father dearly, I dedicate this to my mother, with whom I remain eternally connected in spirit. 

Why?

I commenced drafting this on paper on the anniversary of her sudden death from a fatal myocardial infarction in her home.

That was exactly seven years ago and eerily coincides with my birthday, the 8^th of September.

So perhaps uniting the mortal and immortal worlds regarding birth and death on this day completes another ‘circle of life’ as governed by ‘Samsara’?

Mr Baldev Singh (01/11/30 - 13/01/91) & Mrs Joginder Kaur (15/08/40 - 08/09/15)

(Photographs located during one of my trips to Northern India)

(Of interest, Queen Elizabeth II (21/04/26 – 08/09/22) also passed on the same day. Although I am not an overt monarchist nor a republican, she too is someone I will always remember as having some distant influence in my life).

About the author

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Dr Surrinder Singh is a medical doctor, blogger and freelance writer. He is passionate about healthcare, medicine and education and works professionally with B2B and B2C clients.