The Dying of the Light

By Craig Bowron
Sunday, January 11, 2009

It's January, and with the holidays behind us, here in Minnesota the deep psychosis of winter settles in. The cold has a sharper edge; the darkness of night seems more penetrating and brittle. We'll take the ornaments off the tree but leave the lights on and keep watering it until it gives up its photosynthetic ghost. The green must be cherished until life returns in earnest in the spring.

I'm a physician in a large hospital in Minneapolis, where I help care for patients struggling through the winter of their lives. We've got a lively spring unit, an obstetrical ward where fresh-faced tulips are popping up at all hours, but that's not my specialty. As a hospitalist, I see adult patients of all ages and complexities, most of whom make good recoveries and return to life as they knew it. But taking care of the threadworn elderly, those facing an eternal winter with no green in sight, is definitely the most difficult thing I do.

That's because never before in history has it been so hard to fulfill our final earthly task: dying. It used to be that people were "visited" by death. With nothing to fight it, we simply accepted it and grieved. Today, thanks to myriad medications and interventions that have been created to improve our health and prolong our lives, dying has become a difficult and often excruciatingly slow process.

Take one of my patients. She started dialysis six months ago at the tender age of 85, and the diabetic vascular problems that put her kidneys in the tank persist. One leg has been amputated above the knee, and several toes on her remaining foot have succumbed to gangrene. Robbed of blood, they appear dry, black and tenuously connected, like an ash dangling off a cigarette.

This patient was brought in for a decreased level of consciousness and low blood pressure, but she has been having periods of nausea, and her appetite seems to have died with her kidneys. The initial workup revealed little, perhaps a low-grade bladder infection, but treating it and her low blood pressure doesn't seem to make much of a difference. She is withdrawn; food goes into her mouth, but she won't chew and swallow unless her children instruct her to. She intermittently refuses pills. There's a language barrier, but her children are there to interpret for her. Translation: She feels exhausted and weak, and she feels that way most of the time.

This woman is suffering from what we call "the dwindles," characterized by advancing age and illness. Although dialysis is a miraculous technology -- she'd be dead without it -- it exacts a heavy toll from someone her age or with her medical problems. Three days a week are spent in dialysis, and the other four are spent recovering. It is extending her life, but she's miserable.

Her family has designated her "full code," meaning that if her heart stopped or she were to cease breathing, we would do CPR to revive her, even though there would be a very slim chance of success -- and even though it would be God's or the universe's way of giving her an easy way out.

Another patient is in even worse shape. He's 91 and still a very big man. When I enter his room to examine him, he seems like a giant oak felled into a hospital bed, stiff and rigid, with swollen arthritic joints. A stroke four months earlier paralyzed his right side and left him bed-bound and nearly helpless, with pressure sores on his heels. He is mildly demented, and the pain pills aren't helping. He was brought to the ER because he was thought to be having another stroke, though these new symptoms quickly resolved.

Talking with this patient, I recognize his face and the Cajun accent; I'm certain that I took care of him sometime in the past, but he is not the man he was then. Staring at his 230 pounds stretching the length of the bed, I wonder how difficult it must be to care for him. To transfer him to a toilet or a chair requires the use of a Hoyer lift, a gigantic sling that's wrapped around the patient and attached to a mobile mini-crane. Fully suspended, he looks like a massive baby being delivered by a giant stork. The contortions and gymnastics of getting him slung up and moved must drive him wild with arthritic pain.

Though I reviewed the patient's chart before going into his room, I can't recall seeing what nursing facility he had come from. So I ask the nurse. She tells me, unbelievably, that he has come from his home, where his son cares for him. Later in the day I place a call to this Clark Kent, this Superman in disguise.

The son answers with soft echoes of his father's Louisiana brogue, and I ask him how in the world he manages to take care of his dad. He replies that for one, it's all he does, a full-time job, and moreover, his experiences in Vietnam numbed him to some of the intimacies of caring for another human being. "Once you've shoved some guy's guts back into his stomach, you know, you can get used to the rest of it," he says.

He tells me that his father is wearing out and that it's hard to watch. The arthritis has become quite painful, and sometimes his dad just weeps. Some nights he needs a couple of Vicodin to be able to sleep through the pain. The old man is also spending a lot more time thinking about his wife, who passed away before him. His son thinks he may be ready to die.

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