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