Merry Christmas, Mr Shkreli

I’m having a real problem hating Martin Shkreli.

You probably know about Mr. Shkreli. He is the 32-year-old Wunderkind and hedge fund manager who cornered the market on Daraprim, a medication that  among other uses, is a treatment for AIDS patients  with  toxoplasmosis. His pharmaceutical company became  the world supplier for Daraprim, and raised the medication to  $750 a pill, triggering worldwide outrage and a series of sarcastic op Ed pieces. These pieces all ran along the lines of ” Now that he needs a lawyer, let's charge him $ 10,000 an hour for legal help.”

         Ah Gail Collins, you cut up, you.

 Why the anger?  Could it have stemmed from the Uber self-indulgent you tube videos of him in his Manhattan apartment, blathering on about life as seen through the eyes of a drunk 32 year old Plutocrat?

Is our scorn  based on the concept of cornering the market in a precious commodity?

         American history is filled with those who have done so with  varying degrees of   success and/or fame.  Jay Gould cornered the gold market a century ago.  The Hunt brothers did the same in the 1970s in the silver market.

In any event, we glorify those  scoundrels who have the knowledge and intestinal fortitude to corner commodity markets.

From Ohio Mister Thorne

Calls me up from night 'til morn,

Mister Thorne once cornered corn and that ain't hay.

Aha!

But I'm always true to you, darlin', in my fashion,

Yes, I'm always true to you, darlin', in my way.

--Kiss me  Kate ( as if you didn’t know)

 I’m terrified when scarce drugs suddenly become unavailable for  obvious reasons. I occasionally lose my bottle of  Rapamune, a  GVHD suppression drug,  and I have a buy a few to tide me over. They’re $50 a pill because only one company makes then… well,  they’ve gone generic, so  Sirolimus is somewhat cheaper.  I understand the terror of develping toxoplasmosis, an insidious  parasite that  grows in the brains of the immunocompromised.  Daraprim is the accepted treatment and  now unavailable Fortunately, as is almost always the case,  substitutes exist, so when I develop toxoplasmosis from cleaning the cat litter, I can  probably get by with Bactrim.

Mr. S isn’t alone charging outrageous fees for medications. Amoxicillin costs 2.5 cents a pill  to make.  CVS sells 20  Amoxicillin for $ 48.50,  or  about 2.40 a pill, a mark up of 1000%. Daraprim sold for  17 dollars before Mr. S bought the company he charged $750 a pill, about  1/ 2 of the CVS mark up. I don’t see any of us protesting CVS, although we should for so,so many reasons.

But this case deeply troubles me because I feel we ( that is me, and  you, dear reader, who I hope has a soul, a sense of justice and right versus wrong)  are partially responsible for this sad  situation.

First off,   Amorality doesn’t  evolve in a vacuum. No one sat Martin down as a child and said,

“Martin dear, just because something is LEGAL doesn’t mean it is MORAL and you  should do this. “

Did the guy ever go to church or Synagogue? (I’m afraid to look up which)  Didn’t his parents  ever read  little Martin he teachings of Robert Fulgrum whose  cliché ridden  “What I leaned in kindergarten” should  be taught  at Business schools across the country  because his  preaching, although treacley, is sound.

I believe  Baruch College ,where  Mr. Shkreli   leaned his moral compass, should have  told him:

1. Share everything.

2. Play fair.

3. Don't hit people.

4. Put things back where you found them.

5. CLEAN UP YOUR OWN MESS.

6. Don't take things that aren't yours.

7. Say you're SORRY when you HURT somebody.

         And then  Mr. Trump hits the national stage. He is a creation of the times in which we live.  He is a hero to  multitudes  even though he is the sort of  person the devil assigns to you  in the next world to pay for a life of  greed,  selfishness and close-mindedness.

Trump is an idol, even though his  high rise on central park south (Legally) blocks out the light for several buildings that   once fronted the  park. This wasn’t so bad, I guess until Mr. T  hung a sign that said “ Go Fuck yourself , don’t you wish you lived here?” ( I paraphrase, but that’s really what it said) and made sure it faced the blotted -out building behind his. The man has  infringed on more air rights than a Sicilian  at a  cocktail party ( is this racist? They tend to be close talkers, as a people.)

 The second reason we have to give  Mr. Shkreli a pass is that he was doing what he was trained to do : Find a vulnerable market and exploit it.  I suspect all first year Harvard Business school students are taught a course  titled  “ Exploring  and capitalizing  under -utilized markets” but should probably be called ,“screwing  the poor and ill for fun and profit  ”

 The metaphorical  blood is on our hypothetical hands because we have allowed  big business to control our health care system

Properly done, heath care is a money-losing proposition. Hartford Hospital (  losing  30 million this year)  has a full trauma operating room running 24 hours a day. If your car is  T boned on  Interstate 91 at 3 AM,  rest assured  a capable  vascular surgeon will be available to  sew you up. An OR costs about 2,000  dollars an hour to run even if no surgery actually done,  and someone have to pay that bill.

         We are at fault because we haven’t demanded a single payer  system  for health care for everyone . The thought of veterans dying in the snow because they didn’t have health care is so repugnant to us that we have built an entire VA system that insures this won’t happen.  If  you served your country we won’t let you die in some  hospital parking lot after being  T Boned on the Highway. We wont let a veteran die of Toxoplasmosis  either, for that matter, if we can help it.

         This whole sorry  Shkreli affair could not  happen outside the US, where  the government tightly controls health care.

If  Britain needs more Daraprim, they’ll pay  someone to make more. The Republican Party, home of Mr. T,  insists  people take responsibility for their own healthcare. Everyone has a duty to make sure he or she is covered ,or suffer the consequences It’s  all fun and games until a non veteran  lacking health insurance gets T Boned on Interstate 91 at 3 AM and is brought to Hartford hospital.

         “You don’t have insurance?  You’re not a Veteran? Hm,.. you better go bleed to death in the parking lot.”

That’s not going to happen.

So much of what’s wrong in this country is a result of our own  inability  to protest evil when we see it. I think of the late great Phil Ochs’  “A small circle of friends”

Oh, look outside the window

There's a woman being grabbed

They've dragged her to the bushes

And now she's being stabbed

Maybe we should call the cops

And try to stop the pain

But Monopoly is so much fun

I'd hate to blow the game

And I'm sure

It wouldn't interest anybody

Outside of a small circle of friends

Ridin' down the highway

I don’t have to add that  Phil killed himself a few years back.

What about those poor German civilians   who watched in horror as the  Russian army invaded  Berlin?  What about the atrocities visited upon the women ( as another aside read “All the light we cannot see” for a horrific depiction  of that  small holocaust)

         The German civilians must have cried out as the  Russians tortured them  at the end of World War II, “Its not us! Hitler wasn’t our idea! We are innocent.”

What’s our excuse for watching so much brutality and  cruelty  evolve in our country?  Why don’t we protest the gun lobby and the  private health care industry? Why don’t we really, really care when AIDS patients  can’t afford their medication? We don’t care until  tragedy befalls us.    Jim Brady didn’t give a whit about gun control, until John Hinckley tried to blow his head off. Too little too late, Jim?

I fear my life is spent

No one is innocent

         --urinetown  ( it’s on i tunes, , I guess)

Martin  Shkreli sprang from our loins. He capitalized on a weakness in the system,   exploited the poor and ill in a way that  should make his  business professors  proud and the rest of us a little  unnerved

You taught me to talk

And the benefit is

I know how to curse

---Calliban from the Tempest

The Whitney

The Whitney was crowded but I felt fine.   The Whitney Museum of American art recently re opened in downtown Manhattan after a long run on the Upper East Side. I missed the Whitney. My old friends, the Hoppers, the Picassos and the absurdly obscene instillations were back on display. I roamed room-to-room seeking out my old pals.  I ran into my old friend George Bellows and we both watched the Dempsey – Firpo fight.*

         This was a new experience Not the art, but the disorientation of being well.  Chronic disease is a constant logistical battle.   The mind spins with desperate, absurd, surreal questions. Where is the nearest bathroom?  Sip of water? Where can I lie down if/when I feel sick? If I had to leave,  where is the nearest bed? The nearest hotel room, the next train back home?  Each medication carries its own cacophony   of  side affects  and  Graft versus host disease is like  firing a machine gun into the night. You don’t know where the next bullet will hit  but when it does, there will be pain. Will my  4 ½ year old  white cells  declare  Fatwa against my liver again? My mouth?  My skin?

         The battlefield was clear today.  The analogy of cancer to war is  excellent:  You win the war but the  insurgents hole up and occasionally  descend into town, taking no  prisoners and raising havoc, when you were certain  peace had been declared .

But oddly, this  piece isn’t about me. It’s about Cynthia.

Dear Cynthia , who  stood by me for  the past 8 years of this non ending psycho and melodrama.

         Now its her turn to  search for the closest place to find cool water, a  life saving snack, a clean  and near-by bed.

         Her destroying  angel came in the form of Spondolithiasis.          For  years  her  back had slowly dteriorated. If the spine is a stack of quarters, her spine was more like a game of Jengah where the   wooden sticks are pushed askew. Eventually the stack collapses, the game is over, and it’s time for  serious surgery.  Six weeks ago she had   back surgery where   surgeons trimmed the  overhanging  vertebrate that  were  pressing on her nerves. The surgeons then  made a paste from her bones and spackled the transformed spine to  rebuild the  whittled column that had been her backbone.

          Back at the Whitney, I rush over to greet  my old fried Frank  Stella, who is  hanging out against  a wall . Cyn follows behind, walking slowly, pain etched on her face.

“What’s wrong?"  I ask from reflex. I know that face , the one that  means “I’ve hit the wall, I’ve overdone it and I need to retreat.”  I have a similar face.

And I want to say “I know how you feel. I know exactly how you feel. I know what it’s like to be  77 miles from your bottle of pain medication  and realize you must spend the next 4  hours  seeking out and returning with the  life saving elixir.

                  I don’t want to say “I know how you feel” because she’ll say, “You can’t possibly   know.”

         The conversation will degrade into  a sad  rumination on who suffers more. Please,  Cyn not in front of Frank

         I an amazed and terrified by the similarities of our experiences,  the feeling one can’t go another step, the  nihilistic feeling life will be a series of painful moments, unending  until the  grave’s perfect peace.

         She makes the same ridiculous statements I used to say.  “I’ll never be better.” “ I’m  sure the  treatment didn’t work, They’re lying to me.”

          I find myself having   doppelganger conversations:

“I’ll never  feel better again”

Of course you will

No, no, I will never feel whole again

Of course you will

It is as if we are auditioning for the same role in a play and we pass the  script back and forth to see who sounds more sincere in each role.

Cyn has taken on a dreadful habit I once enjoyed: She wakes and rates the day ‘ Today will be a B-. Today will be an F. I once did the same. No need now, I’m settling into that B+/A- state  that's good for most but will keep you out of medical school.

What amazes me is that Cyn and I are so different. I am  everything she is not. I am  maudlin , vindictive ,  sentimental and  self pitying.  Cyn   exudes confidence and calm, her father’s eys looking out at world  from which he has departed. Cyn and her dad hate self pity, I  turned it into an Olympic event.

         Cyn was recently named  VP of  primary care at our hospital. She has done an amazing job  reigning in  and soothing the  4^th grade  fragile yet preposterously self important egos of most docs. Had I been given the position, I would spend my time  evening up the score, firing anyone who had offended me over the past 18 years.  I'd soon be alone.

         My  self pity led me to believe there is nothing, save the suffering  of one's child , than one’s own suffering. I have always felt  the Deity  singled me out for some karmic retribution,  that is, until I tell someone of my fate and  he or she replies with a tale so grotesque and horrible  I am driven to ashamed  silence.  I am merely miserable; I am not among the horrible.

         I feel that life is divided into the horrible and the miserable. That's the two categories. The horrible are like, I don't know, terminal cases, you know, and blind people, crippled. I don't know how they get through life. It's amazing to me. And the miserable is everyone else. So you should be thankful that you're miserable, because that's very lucky, to be miserable.”

 ---Woody Allen

         But there is something worse than one’s own suffering. The suffering of one’s mate is far worse.

In suffering one has pity,  one has carte blanche to be  sad and bitter, to lash put against loved ones,  to transgress in a million innocent and not so inniocent ways . There is  perfect peace in  being terminally ill, as I learned when my disease roared back and I was beyond chemotherapies’ ambivalent  but sometimes helpful grasp.  .  I have known all of Kubler Ross’s  stages of grief, even the last stange, acceptance ,which is not acceptance in the  positive, life affirming  style   but  the feeing  the mouse feel’s as she is borne from earth in an eagle’s mouth.

         Once upon a time I ached over my neoplastic fate, the pain of  cancer therapy, of  relapse, of  endless side effects.  Cyn was there every step of the way.  Now I know the utter helplessness of watching one's loved ones suffer, knowing there is nothing, really, that can be done to assuage her pain. 

Now its my turn to ache again, over the sufferings of my dearest.  

Update: Just got back from the  orthopedist. Mike  is a jolly,  reassuring guy, who reviewed Cyn's X rays and said " You' re doing great"

ptoo ptoo ptoo

Maybe life is retiuring to the daily  disater of mere misery. I hope.

* A tad obscure. Sorry. George Bellows (1889-1925 American painer. Paineted Dempsy Vs Filpo ( 1924) Love the pic because  Bellows is the bald guy to the left.  I live my life for  inside art jokes. 

George Bellows/ He's the  bald guy on the left

 Frank Stella

Jenga. That's What Cyn's spine looked like

take two

 He was fighting a losing battle against cancer and was receiving experimental chemotherapy.   His spouse demanded everything be done to keep him alive.  “He’s too young to die, we have small children,” she sobbed. I suggested making him DNAR, do not attempt to resuscitate, and she became angry. 

“Boston  tells us the chemotherapy might work, and if you make him a no-code, you have extinguished any hope we might have.”

The Hospital called.  He was failing. He was on pressors, intravenous medicines used to maintain blood pressure at times of crisis.

“I’ll come right down, “ I said. I would speak to the spouse, discuss the perils of being a patient with advanced cancer who underwent cardiopulmonary resuscitation.

By the time I arrived at the intensive care unit, he was gone. He lay on a gurney, eyelids open,  eyes bulging from their sockets from the 30 minute-long  attempt to retrieve him.  His expression was one of abject terror.

His arms were swollen and bleeding, stigmata from multiple attempts to insert 18 gauge needles as he lay dying. I beheld a scene of un imaginable violence.  

  My patients with advanced disease who undergo in-house  CPR share  a common fate. They all die alone, without family in attendance.  When CPR begins, the family is hustled out, useless civilians driven from a battlefield, an alien arena in which they are useless.Worse, their weeping and attempts to comfort their loved ones makes resuscitation hazardous for patient and family members alike.  One cannot  embrace a loved one receiving  a 360 joule electro conversion shock. 

                     I am wary of buildings bearing messages, Work Makes One Free, Ignorance is Strength, but the portal to every Medical school and hospital should bear the warning:

  Death is not the enemy, Suffering is.

Modern medicine has forgotten this simple truth, at our own peril.

             I have taken to making house calls.  Some patients are bed bound, so I throw my stethoscope in the Honda, don a white lab coat and drive Connecticut streets, seeking my wayward patients.

            The results have been startling.

            I enter a house. The patient lies in the living room, in a hospital bed, dying.

In our storied past, loved ones died of old age.  Once upon a time, we died at home.   We died upstairs in the master bedroom, covered in a hand -made quilt as family members said goodbye, reminisced, shared the vigil against encroaching night.

Nowadays, no one dies of old age.  The term itself has become vaguely grotesque, politically incorrect, and pessimistic. Patients die of atypical tuberculosis, protein wasting syndrome and immunodeficiencies, By giving name to these conditions, we imply that treatment, and hence salvation, exists.

 I blame Dylan Thomas.  We have taken his admonition to rage against the dying of the light to heart

Family members approach me. “ What did Boston tell you?”   Boston, medical Mecca, has become shorthand for,   "the place where my loved one will receive a lifesaving diagnosis and treatment.”

           

I blame ourselves as medical providers. We sometimes encourage futile therapy, claiming to restore hope but forgetting that  the new proposed therapy has the  slimmest chance of success, at the  expense of additional suffering for patient and family.

Insurance companies’ policy rates are skyrocketing.  I am not excusing their behavior but rates increase when we decide as a culture that a brain MRI or 30 minutes of a cardiopulmonary code would be more therapeutic than soft classic music in an upstairs bedroom where the lights are low and the air smells of lavender lotion. 

To be fair, we are staring to recognize that a patients’ death is not necessarily an indication of our failure.. We now use the phrase: Do not Attempt to resuscitate, rather than Do Not Resuscitate.   This subtle shift suggests there is no magical procedure to return our loved one from the banks of the River Styx.    We need to teach our medical students that every patient will eventually die, will eventually fail to respond to  any number of  expensive treatments and uncomfortable testing.

This raises the point: Is Cardiopulmonary Resuscitation ever useful, especially for  patients with cancer?

The answer lies in a patients’ health prior to  CPR.  If an otherwise healthy patient with cancer ( or without cancer, for that matter)  suffers  a cardiac arrest,  CPR offers a reasonable chance the patient will leave the hospital alive. For debilitated cancer patients (defined as those who spend at least 50% of the day in bed) a 2002  study pronounced   Hospital based CPR “ Futile.”

       I have been fighting  Chronic  Lymphocytic leukemia since 2007, and underwent  a stem cell transplant in 2011.   I wrote of my disease and the need for universal vaccinations in a 2011  New York Times op ed piece. I wrote that cancer taught me the value of community.  Cancer has now taught me that death is not the enemy, suffering is. I am in remission ( excuse me, Ptoo ptoo) but suffer  daily from Graft verses Host disease, an insidious  syndrome in which my donor cells attack my own innocent tissue.  I have experienced days so  pain filled that I  wished I could end my suffering in any way possible.  I don’t mind dying, I dread suffering, especially without a reasonable expectation my misery will end.  I view CPR for the terminally ill as a form of needless misery.

       My patients are becoming more involved in their healthcare. They demand that I review their CT scans and blood work with them.  I see real irony here, but I also see a chance for improving health care delivery. My patients panic when their MCHC  (mean corpuscular hemoglobin concentration) is elevated. They want to know what that means, The honest answer is  “if you are not anemic,  an isolated abnormal MCHC doesn’t mean much.”   I wish they showed as much interest in their DNAR status. We ask our patients to sign DNAR papers which describes CPR in the mildest terms .  Our form reads, in part

        if you stop breathing would you allow a tube to be       inserted into your throat?

       These forms should be more honest and more accurate. They should read:

       The chance of survival  in any patient with any terminal disease who undergoes an insertion of a breathing tube and  the application of electrical shock to the chest is essentially zero. During this attempt at resuscitation, you may experience pain, anxiety and fear. If you require the insertion of a breathing tube, your family will be forced to leave the room and there is a possibly you will die in pain and without loved ones around.

       I contemplated requiring  all patients requesting “ full code status, no matter what” to watch a video  of a patient undergoing  CPR, but that would be too gruesome  to watch.  Viewing such a video could produce its own suffering.

        If I were hospitalized because my cancer had returned, I am certain I would request DNAR status .

       A Johns Hopkins study found 90% of all graduates from the Johns Hopkins school of Medicine would decline CPR unless they had an acute, treatable condition. We  physicians have  run or watched  too many attempts at cardiovascular  resuscitation  to want this procedure performed on us.

        When my time comes, I want to die in my bed,  the sound track of  Kiss me Kate  playing in the background, a generous dose of morphine and Ativan  soothing my central nervous system and the  healing scent of chicken soup wafting up from the kitchen. Wouldn't you?

Death be not a stranger

Note:  Hartford Hospital’s legal department has warned me to state that the following article  does NOT pertain  to any specific person, all details are composites used for illustrative purposes only. So, back off.

            I am wary of buildings bearing messages, Work Makes One Free, Ignorance is Strength, but the portal to every Medical school should bear the warning:

            Death is not the enemy, Suffering is.

            Modern medicine has forgotten this simple truth, at our own peril.

             I have taken to making house calls.  Federal guidelines demand all patients discharged from hospitals be seen by a physician within 45 day of discharge. Some patients are bed bound, so I throw my stethoscope in the Honda, don a white lab coat. and drive Connecticut streets, seeking my wayward patients.

            The results have been startling.

            I enter a house. The patient lies in the living room, in a hospital bed, dying.

In our storied past, the loved one would be dying of old age.  Once upon a time, we died at home.   We died upstairs in the master bedroom,  covered in a hand -made quilt as a stream of family members  said goodbye,  reminisced, shared the vigil against encroaching night.

Nowadays,  no one dies of old age.  The term itself has become vaguely grotesque, mocking, and politically incorrect.

My 90 year olds  die of atypical  Tuberculosis, renal failure, immunodeficiency, but never of old age.

This distinction is problematic.

I blame Dylan Thomas.  We have taken his admonition  to rage against the dying of the light to heart.  Family members no longer visit to hold  hands, offer a sip of something cool and sweet, or to reminisce, often in the mother tongue, about life  in another land , another century.

            Family members approach me. “ What did Boston tell you?”   Boston, medical Mecca, has become shorthand for  “ the place where my  loved one will receive a lifesaving diagnosis and treatment.”

            Family members are angry “ The Boston doctors said that  chemo would save his life,” or “The doctors at the Farber think  this may be caused by an obscure  immunodeficiency.”

            Once upon a time,  people died of old age. Now they die of IgG4 deficiency syndrome.

No one wins in these situations.

Family members are angry about missed diagnoses, missed chances. “The Boston doctors told us if he received treatment, he would be OK.”

            To be fair, my colleagues on Longwood Avenue  usually don’t make  these bold statements. People hear what they want to hear, but this misses the point.

            My patients are dying because their time to die is nearing.  We do our patients a grave disservice by raging  against  inevitable mortality,  when we should be  holding a parents’ hand,  giving a loved one a chance to talk about life in  Russia or Poland or Hartford in the 1930s.

I read in today’s Times that  Insurance companies  are  raising their rates. I cannot condone their behavior, this isn’t problem in any  other first world country.  I suspect this is partially  because Europeans  treat death  not as an enemy, but as constant companion who will eventually point to his watch and say,  “Time’s up, come with me.” Rates go up when we decide as a culture that a  brain MRI would be more therapeutic than soft classic music in an upstaird bedroom where the lights are low and the air smells of lavender  lotion. 

            I am troubled  that we mask our fear of death  by our insistence on chasing medical miracles.   Sometimes, we should  concentrate on alleviating uncomfortable symptoms, not seeking panaceas.    I  talk to  family members  about  methods to control pain,  reduce anxiety, improve appetite, and treat insomnia.  These conversations are sometimes perceived as an admission of failure. Worse, my suggestion to  increase  a morphine dose is perceived as my confessing that I am a quack.  If I were really smart, I would  have devised an elegant scientific  plan to  prolong a patients life. My attempts to alleviate pain would not be considered a  ham–fisted attempt to  cover my tracks,  sending a misdiagnosed and mistreated loved one to the great beyond prematurely in an opium  tinted haze.

Medicine is too slow to adapt to the obvious but unfamiliar  concept that  physicians will eventually lose every battle against death.

            We once  used the phrase “DNR” meaning “Do not resuscitate. ” This  concept  carries a  dangerous conceit that there exists a  procedure that will bring a patient back to life.   DO NOT resuscitate suggests a rejection of  a life saving technique.

We now use the phrase : Do not Attempt to resuscitate.  This subtle shift suggests there is no magical procedure to return our loved one from the  banks of the River Styx.

            Death is the new sex.

            Once,  sex education wasn’t taught in schools.  The concept of procreating made us uncomfortable.  We were afraid our children would become obsessed,  irrational, and lascivious if they  learned about procreation and contraception.

            We don’t teach death Ed classes, the concept  sounds morbid, bizarre, Adams family -esque.

            The analogy is apt, When  the religious right preaches abstinence only programs, in essence, denying human sexuality,  the results is an uptick of STDs and pregnancies.

 Medical schools  teach of medicine's  miraculous healing powers.   Hospice education reeks  of failure.  “Palliative care, eh? What,  you couldn’t figure out what the patient was dying of?’ Is the  inherent message.

            We need to teach our medical students that every patient will eventually die,  will eventually  fail to respond to  any number of  expensive treatments and uncomfortable testing.

            The Roman gladiators  were once pursued by a companion who would intone,  ”Thou art  mortal Thou art  mortal” to remind the  athletes that  his  finely honed physique was  not immune to sword and sling shot, not to mention Dengue fever.  I want every medical student to be reminded daily  “Your patients are mortal,  every single one will die.”  Lenny Bruce once urged that we  utter racial epithets throughout the days., in this way he proposed, the hateful words would lose their sting  and therefore,

you could never make some six-year-old black kid cry because somebody called him  a  ****** at school.

Perhaps if we  told every patient  “You will die, you will die, you will die.”  the emotional wallop would fade and we could  concentrate on what is important:  comforting the sick and accepting their inevitable departure