How We Die

Sometimes when I close my eyes and my mind wanders, I think about death. Not my own, usually, but of the many patients I see in the hospital that are on the edge, living their last few moments in a tiny white room on the eighth floor with no view. Medications, drugs, and fluids are pumped into them as they negotiate the fine line between life and death, slowly inching towards an inevitable fate. When I close my eyes, I can see the 75 year old man who shot himself in the belly, lying with his mouth wide open. A propofol drip keeps him sedated. He won't make it. I see him from my chair in the nurses' station, visible through the clear sliding doors of the Intensive Care Unit. Six floors up is an 85 year old woman fighting off metastatic melanoma. But she really isn't the one fighting; her husband wants absolutely everything done, even if it only means a few more days or weeks, and even if it causes pain. Agony is irrelevant; death is avoidable. I see her as I sit at the foot of her bed, as her husband tells me that God gave doctors the power to heal. Anything less than a war against this disease would be going against God. I sit and listen.

These images remind me of my own mortality. The thought of spending my last days in a hospital evokes a visceral reaction. If I make it to the ripe old age of eighty, I will view every additional moment as a blessing. But, I don't want to be anywhere near a hospital at that point (as a patient, of course; I may very well still be practicing). This feeling has grown stronger over the past six months. Every time I see another 95 year old admitted, I ask myself, "Does she really want to be here?" This can't be the last place where you would want to live. A place where we wake you up every couple hours to take your vitals, a place without a breeze, a place that is not a home.

There are millions of good reasons to be in the hospital. I'm just not sure "dying" is one of them. And I'm not the only one in my field who feels this way. I was sent an article from our Ethics professor, Dr. Meacham, called How Doctors Die, which better explains how many doctors feel about the inevitable.

Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds—from 5 percent to 15 percent—albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.

It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

Part of taking a full History and Physical is asking about the "social history." This is where we document such things as tobacco and alcohol use, family support, and prior occupation. I haven't been at this long, but I have yet to meet an older patient in the hospital who has been a physician. I haven't met enough patients to have a large sample, but perhaps this fact is not surprising. The place where many of us will work for thirty-some years is the last place we want to spend our "free time." It will be something to keep track of though; I look forward to hearing the thoughts of a physician spending his last days in the hospital, or of anyone who has worked much of their life in the place with no breeze that is not a home.

Over the next several weeks I will be preparing to drive back to Washington, DC for the Christmas holidays. I have sent the above article to my immediate family, because I want to talk about last wishes over break. I want my wishes known, and I want to know exactly what my family members want, especially while all of us are healthy and thinking clearly. I will review my living will and make sure that nothing has changed over the past few years. I think this is when the best decisions are made: before, not during, the weight of the moment.

As I watch the propofol and chemotherapy drip, I ask myself if this is how I would want my family members to live their last days. That choice is up to them, but I will choose to watch the sunset without IV drips or blood pressure cuffs. I want to feel the cool breeze through my own window.