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The Dying of the Light
Nothing in my medical training qualifies me to judge what kind of life is satisfying or worth living. Many would say that if we were to become paralyzed in an accident, just let us die. But many quadriplegics, once they've gone through an initial period of adjustment, find their lives very satisfying. Patients can and do make enormous efforts and fight precipitous odds to get back to life as they knew it, or even just to go on living. But the difference for many elderly is that what's waiting for them at the end of this illness is just another illness, and another struggle.
Another patient of mine has 86 years behind her and was brought to our hospital from a nursing home in the wee hours of the morning. Her diabetes has become very brittle and difficult to control; the day before, paramedics were called because her blood sugar had dipped so low that she was becoming unresponsive. She also has dementia, and a couple of months ago, she fell and broke a hip. Although it was repaired and she completed rehabilitation, she has wound up essentially bedridden. Strictly speaking, losing your mind won't kill you: It's the falling, the choking, the weakness, the bed sores.
This patient was brought in because the nursing home staff thought that she might have aspirated some food or secretions and developed pneumonia. She thinks it's 1982 and is, as we say, "pleasantly confused." She denies any and all symptoms, and her breathing looks comfortable. A review of her chart shows no fever and a normal white blood cell count. Her chest X-ray shows perhaps a subtle pneumonia but also a compression fracture of one of her vertebrae, which has gone from being 50 percent to 90 percent collapsed. Her dementia has mercifully spared her a lot of pain from the fracture, but it also keeps her from recognizing members of her extended family. Sometimes she doesn't recognize her own son, who drove to the hospital to be with her at this early hour.
He and I discuss what brought her in, and then we talk about her code status, which he confirms is Do Not Resuscitate. "She wasn't supposed to be brought to the hospital in the first place," the son tells me, and puzzled, I ask him to say that again. She was never supposed to be hospitalized: Whatever troubles arrived, the plan was to deal with them in the nursing home. His mother had made that decision herself, several years prior to this hospitalization, before the dementia really set in.
Later that day, I meet with the son and a few other close family members. They want to continue the medications that would bring their mother comfort and discontinue all the rest. They aren't looking to end her life, but they aren't looking to prolong it, either. They can see that she is moving away from them in both body and mind, and they are ready to let her go.
To be clear: Everyone dies. There are no life-saving medications, only life-prolonging ones. To say that anyone chooses to die is, in most situations, a misstatement of the facts. But medical advances have created at least the facade of choice. It appears as if death has made a counter-offer and that the responsibility is now ours.
In today's world, an elderly person or their family must "choose," for example, between dialysis and death, or a feeding tube and death. Those can be very simple choices when you're 40 and critically ill; they can be agonizing when you're 80 and the bad days outnumber the good days two to one.
It's not hard to identify one of these difficult cases in the hospital. Among the patient-care team -- nurses, physicians, nursing assistants, physical and occupational therapists, etc. -- there is often a palpable sense of "What in the world are we doing to this patient?" That's "to" and not "for." We all stagger under the weight of feeling complicit in a patient's torture, but often it's the nurses who bear most of that burden, physically and emotionally. As a nurse on a dialysis floor told me, "They'll tell us things that they won't tell the family or their physician. They'll say, 'I don't want to have any more dialysis. I'm tired of it,' but they won't admit that to anyone else."
This sense of complicity is what makes taking care of these kinds of patients the toughest thing I do. A fellow physician told me, "I feel like I am participating in something immoral." Another asked, "Whatever happened to that 'do no harm' business?"
If we can be honest and admit that we have no choice about dying, then the only thing we do have a say in are the circumstances. Like many nursing home patients, Dorothy was on the cholesterol-lowering medication Lipitor. Why? So that she wouldn't die of a heart attack or a stroke. But don't we all die of something?
Everyone wants to grow old and die in his or her sleep, but the truth is that most of us will die in pieces. Most will be nibbled to death by piranhas, and the piranhas of senescence are wearing some very dull dentures. It can be a torturously slow process, with an undeniable end, and our instinct shouldn't be to prolong it. If you were to walk by a Tilt-A-Whirl loaded with elderly riders and notice that all of them were dizzy to the point of vomiting, wouldn't your instinct be to turn the ride off? Or at the very least slow it down? Mercy calls for it.
This isn't about euthanasia. It's not about spiraling health care costs. It's about the gift of life -- and death. It is about living life and death with dignity, and letting go.
In the past, the facade of immortality was claimed by Egyptian kings, egomaniacal monarchs and run-of-the mill psychopaths. But democracy and modern medical advances have made the illusion accessible to everyone. We have to rid ourselves of this distinctly Western notion before our nation's obesity epidemic and the surge of aging baby boomers combine to form a tsunami of infirmity that may well topple our hospital system and wash it out to sea.
At some point in life, the only thing worse than dying is being kept alive.
Craig Bowron is a hospital-based internist and a writer in St. Paul, Minn.