Death Becomes Us

I've been thinking a lot about death lately.  In part, it's due to the fact that I just finished watching all five seasons of "Six Feet Under," but it's also due to the fact that I have been encountering death on an almost daily basis for the last 6 weeks.  One of my duties as a House Physician is to pronounce patients who have died while in the hospital.  Since I have been working 24 hours on and 24 hours off for a greater part of the last 2 months, I have had more than my fair share of pronouncements.
The oncology ward is on the 8th floor here at Fairview Southdale, so the majority of my calls are to this floor.  A colleague of mine has had up to five deaths in one shift.  My record is three.  These patients are usually in the end-stage of their cancer, and they are admitted as "comfort care" meaning, they receive pain medications and are kept "comfortable" in anticipation of their impending death.  Families are usually prepared.  They stay in the room as I do my exam.  It's often a very calm experience.
Contrast that to calls I get to the ICU.  There patients usually die of an acute process, most often, a massive heart attack or stroke.  Families are in shock and disbelief.  It is never a good situation.  But, families usually come to understand that the severity of the illness was so catastrophic that survival wasn't possible.
But, my rant today isn't for those patients.  It's for the patients for whom there is no hope.  Who've suffered that catastrophic illness and are kept alive because of medical technology.  My story today is of the two Russian ladies.  Both spoke no English.  Both lived alone.  Both were in their late 70's/early 80's.  And both fell down at home alone.
The first lady was found by her family about an hour later.  She was admitted to the hospital with severe back pain.  I was called to see her because her back pain was getting worse, and she was having difficulty breathing.  In med school you're taught that "sudden-onset ripping severe chest pain" means aortic dissection until proven otherwise.  And, she had the symptoms to go with the diagnosis.  As I watched her oxygenation saturations drop, I asked her, via interpreter, did she want to be intubated (breathing tube placed and put on a ventilator).  She replied, "No, I've lived a long life, and I don't want any extra-ordinary means keeping me alive."  When her EKG showed that she was having a massive heart attack, I asked her about doing chest compressions and starting medications should her heart stop.  Again, she said, "No." 
The other lady was found down immediately.  She was brought into the Emergency Department and found to have bleeding in her head.  She was admitted, and she was actually doing well until the morning I was called because she had become unresponsive.  She was showing signs of brain injury, and, because her family had said they wanted everything done, she was intubated and placed on a ventilator.  An MRI showed no new bleeding, but she never awoke again.  After an EEG showed minimal brain activity, her family had been asked if they felt she would want to continue doing everything to keep her body alive, they said, "Yes."  Because she could not tell us, and because she had no advanced directive or living will, her family made the decisions for her. 
This morning, on my way to pronounce a patient in the ICU, I heard that the family wanted to have a permanent airway (a tracheostomy) placed in her neck so that she could be on a ventilator long term.  I started having feelings of anger and indignation which were shared by the respiratory therapist who had told me of their decision.  I was still shaking my head as I came to the room of the patient who had died.  It was this second Russian lady. 
She was still on the ventilator, but her heart had stopped.  The family would not let the nurses turn off the ventilator until I pronounced that she was really dead.  I went into the room and did my exam.  When I nodded to the nurse, he quietly turned off the ventilator.  The family remained in the room, visibly upset.  I feel in some way, she finally made her own decision and let go.
My whole point in writing this, aside from the fact it's my blog and I can rant if I want to, is to illustrate the importance of having frank discussions about death and making your wishesknown. 
My mother and I have always had an open dialogue when it comes to her wishes.  Her only concern is that I might "pull the plug" too soon because I might be too interested in my inheritance.  But, she knows that if something were to happen to me, I want all organs to be donated.  Then I want to be cremated and separated into 5 mini urns to be taken by family and friends whenever they travel.  She knows I am going to turn a part of her into a diamond.  (lifegem.com)  She's just jealous because she loves diamonds and won't be able to have one of her own.
My best friend Nicole wants to be cremated and have her ashes spread in Lucerne, Switzerland.  We once had a conversation that if she went first, I'd make sure they got there.  If I went first, she promised to have some of my ashes taken to be spread with hers.
Death isn't to be feared.  It's the one fact of life that we will all share.  So share your wants and desires before someone makes decisions for you.  Frank discussions and planning with family and loved ones will help so much when the time comes.  Make a plan, appoint a power of attorney for health care, make a living will. 
Talk about organ donation.  Be a part of the Green Ribbon team and sign the back of your driver's license, but also make sure to talk to your spouse and family members about your wishes.
My favorite poem:  Crossing the Bar, Alfred Lord Tennyson
Sunset and evening star,
And one clear call for me!
And may there be no moaning of the bar,
When I put out to sea,
But such a tide as moving seems asleep,
Too full for sound and foam,
When that which drew from out the boundless deep
Turns again home.
Twilight and evening bell,
And after that the dark!
And may there be no sadness of farewell,
When I embark;
For tho’ from out our bourne of Time and Place
The flood may bear me far,
I hope to see my Pilot face to face
When I have crossed the bar.

Tags: death, Tennyson, organ donation, end of life issues