It wasn’t the first time nor will it be the last, I’m sure.
It wasn’t even a special event for me. I have been practicing medicine since 1978 and have seen all manner of death – traumatic death, septic death, brain death, hemorrhagic death and the ultimate; cardiovascular collapse.
In my opinion there are definitely better ways to die and messier ways to die… Rarely does the patient get a choice, but know this: all living beings die.
The patient was a gentleman whose last days were spent existing in that most modern of American institutions, the nursing home. He had so many medical maladies he is what Doctor Shem used to call a PPP, Piss Poor Protoplasm. No organ system in his body was working right; even his skin seemed to be on the verge of collapse.
He had endured his strokes, made it through triple bypass surgery, and had survived to a truce with his acute renal failure. In fact for a time all the failing systems had actually achieved a balance with each other. We call that homeostasis.
The factor that had unbalanced what had been balanced was anyone’s guess.
He was found unresponsive with a blood pressure to bust the O-ring, a possible sign of some problem with the brain. When you add the copious amount of bloody vomitus found on his face this was probably as good a guess as any for a diagnosis.
You see, when the brain is hurt it causes patients to sometimes profusely vomit.
I can’t tell how long the patient was in this state before being found; certainly enough time for him to vomit and then “breathe in” or aspirate the bloody, highly acidic liquid into his lungs. His lungs filling with this vile concoction would no longer be able to efficiently transfer oxygen from his inspired air to his blood. The cells in his body needed that magic element to continue their metabolic processes. Cells would start dying, slowly at first, then quickly and in scores.
A cascade of system failures began, and, probably much like the control room at Fukashima or Three Mile Island the red warning lights would start to strobe, the claxons would blare, and system after system would cascade into failure.
The paramedics were summed to the nursing home and the patient’s folder of medical information would be put through the copy machine including a copy of his last request, the DNR, his refusal to allow the attempt to save his life.
I do not have a DNR filed. I do not know many of my friends that do. When you sign your name to that document you confront your own mortality. I believe it takes a certain inner strength to do so… You are your own judge signing away the one or two chances you have to prolong your life. Some might say it’s cowardice; a human being fights to survive. To that I say walk a step in a terminal man’s shoes – it will quickly disabuse you of this notion.
The decision to sign is a profoundly personal one that (in my experience) is better made by the patient and not by his loved ones. Loved ones are prejudiced by the very love they have for their beloveds… Almost a selfish love. I want (Husband, Wife, Mom, Dad, Grandpa, Grandma, Sister, Brother… check one, two, all) to be with me forever regardless. I am not knocking the family members… I wanted my parents to be around forever also, to see the accomplishments of their sons, grandchildren, great grandchildren to the n’th generation. Selfish, but understandable. However the patient has to live the consequences from the decisions made by his family. Heart failure causes periods of pain in the chest, constant shortness of breath when exerting yourself, tiredness, and mental fogginess. You don’t function well, and it gets worse – not better. Respiratory failure makes all exertion feel like you’re climbing Everest. You have trouble walking from the parking lot to the store. Lifting makes you gasp, and that basic of intimacy toward a special loved one – making love – becomes impossible. Life becomes a daily struggle, and soon that struggle becomes a constant in life. Eventually the battle is lost.
I’m (sometimes) able to sincerely tell a patient’s family that Grandpa came to a peaceful end after living a full and rich life. He made it to 86 or 93. He died doing something he loved – working on the house, cooking for his loved ones, being in bed holding his cherished partner… He was healthy enough to participate without much pain or inconvenience in his old age.
Last night, I could not give these words of comfort to a large, loving family that had gathered by his body to say goodbye. This husband, father, and grandfather had not died well. All I could think of was, thank God he had given himself the gift of death. I thanked God that the paramedic who had respected his wishes expressed by that simple official “Do Not Resuscitate” document had prevented me from doing something stupid and disrespectful like trying to save him.