Authors: Sherwin B Nuland
How We Die (24 page)
For Osler himself, the very end did prove to be peaceful. It was bought, nevertheless, at the cost of much suffering, which even his perpetually cheerful nature was not able to overcome. His final illness lasted two bedridden months, beginning with symptoms thought to be caused by a cold, then influenza, then pneumonia. Though he bore bravely the high fevers and agonizing bouts of uncontrolled coughing, it was sometimes difficult to reassure his wife and worried friends that his optimism was not wilting. Late in his sickness, he wrote in a letter to his former secretary, “I have been having a devil of a time—in bed six weeks!—a paroxysmal bronchitis, not in either of your books! practically no physical signs; cough constant, short couples and then bouts, as bad as whooping cough. . . . Then the other night, eleven o’clock acute pleurisy. A stab and then fireworks, pain on coughing and deep breath, but 12 hours later a bout arrived which ripped all pleural attachments to smithereens, and with it the pain. . . . All bronchial therapy is futile—there is nothing my good doctors have not made me try, but the only things of any service whatever in checking the cough have been opiates—a good drink out of the paregoric bottle or a hypodermic of morphine.”
By then, even a spirit as bright as Osler’s was flagging, as well as losing its ability to convey optimism to those around him. He had undergone two operations under general anesthesia to drain the pus accumulating in his chest, and each had left him only briefly improved. His torment made him long for the death he had described fifteen years earlier, in which he would be “generally unconscious and unconcerned.” Toward the end, the courageous Osler admitted both the difficulty of his passage and his longing for the suffering to end: “The confounded thing drags on in an unpleasant way—and in one’s 71st year the harbour is not far off.”
Two weeks later, Osler was dead, at the age of seventy. He had lived the threescore years and ten promised by the Book of Psalms. His pneumonia had not been the “acute, short, not often painful illness” that he had long ago described, and it had certainly not fulfilled its function as “the friend of the aged,” since he almost certainly would have had many healthy years ahead of him had he not been felled by it. And thus his dying betrayed his expectations, as it will for most of us.
By and large, dying is a messy business. Though many people do become “unconscious and unconcerned” by lapsing or being put into a state of coma or semiawareness; though some lucky others are indeed blessed with a remarkably peaceful and even conscious passage at the end of a difficult illness; though many thousands each year quite literally drop dead without more than a moment’s discomfort; though victims of sudden trauma and death are sometimes granted the gift of release from terror-filled pain—conceding all of these eventualities—far, far fewer than one in five of those who die each day are the beneficiaries of such easy circumstances. And even for those who do achieve a measure of serenity during separation, the period of days or weeks preceding the decline of full awareness is frequently glutted with mental suffering and physical distress.
Too often, patients and their families cherish expectations that cannot be met, with the result that death is made all the more difficult by frustration and disappointment with the performance of a medical community that may be able to do no better—or, worse yet, does no better because it continues to fight long after defeat has become inevitable. In the anticipation that the great majority of people die peacefully in any event, treatment decisions are sometimes made near the end of life that propel a dying person willy-nilly into a series of worsening miseries from which there is no extrication—surgery of questionable benefit and high complication rate, chemotherapy with severe side effects and uncertain response, and prolonged periods of intensive care beyond the point of futility. Better to know what dying is like, and better to make choices that are most likely to avert the worst of it. What cannot be averted can usually at least be mitigated.
No matter the degree to which a man thinks he has convinced himself that the process of dying is not to be dreaded, he will yet approach his final illness with dread. A realistic sense of what is to be expected serves as a defense against the unrestrained conjurings of warrantless fear and the terror that one is somehow not doing things right. Each disease is a distinctive process—it carries its own particular kind of destructive work within a framework of highly specific patterns. When we are familiar with the patterns of the illness that afflicts us, we disarm our imaginings. Accurate knowledge of how a disease kills serves to free us from unnecessary terrors of what we might be fated to endure when we die. We may thus be better prepared to recognize the stations at which it is appropriate to ask for relief, or perhaps to begin contemplating whether to end the journey altogether.
There is a kind of dying for which very little or no preparation is possible, and perhaps not advisable. Death by violence is by and large the province of the young. Even when forewarned, youth does not heed the counsel that advises an acquaintance with the avenues leading toward the grave. Neither is youth influenced by statistics—trauma, defined as a physical injury or wound, is the leading cause of death for all persons below the age of forty-four in the United States. It kills approximately 150,000 Americans each year, of all ages; an additional 400,000 are permanently disabled. Sixty percent of the mortality occurs within the first twenty-four hours after injury.
Not surprisingly, our nation’s leading source of trauma is automotive. Some 35 percent of major injuries are sustained by automobile occupants and another 7 percent by motorcyclists. The vehicular injuries have at least the virtue of being unintentional in the vast majority of cases. Not so with gunshot wounds (which account for 10 percent of all major trauma) and stabbings (which add almost an equal number). Pedestrian accidents make up 7 to 8 percent, and an additional 17 percent result from falls, which so often involve the very old and the very young. The remaining 15 percent of major traumas arise from a variety of sources, including industrial accidents, bicycle crashes, and an assortment of suicide injuries.
On a late summer day in 1899, a sixty-eight-year-old real estate broker, ironically bearing the name Henry Bliss, stepped off a trolley car in New York City and was killed by a passing automobile, thereby acquiring the dubious distinction of becoming our country’s first automotive traffic fatality. Since then, almost 3 million people have died of motor vehicle injuries. The most important contributing cause in those deaths (their traveling companion, so to speak) has been alcohol. Alcohol is a factor in approximately 50 percent of motor vehicle deaths in the United States. One-third of those who have died were victims of someone else’s drinking.
Having argued that individual death is of necessity an integral component in the pattern of biological continuity, I add here the self-evident wisdom that nature requires no help. Her own cellular manipulations render unnecessary and ultimately counterproductive our killing of vast numbers of each other, and of ourselves. Trauma robs the species of its progeny and violates the orderly cycle of renewal and improvement. The traumatic death of a human being serves no useful purpose. It is as tragic to the species as to the family left behind.
How ironic it is, then, that so little of our society’s biomedical effort is focused on the prevention and treatment of injuries. Only recently has violence been recognized as a major public health problem in the United States—that the number of deaths due to firearms in our country is, per capita, seven times the figure for the United Kingdom; that the frequency of suicide, the most grievous face of violence, has doubled among children and adolescents in the past thirty years, an increase due almost completely to firearms. Suicide is now the third-leading cause of death in those young age groups.
There are those who argue persuasively that the figures for suicide are much too low; they do not include that insidious form of gradually self-destructive behavior some call “chronic habitual suicide”: drugs, alcohol, unsafe driving, dangerous sexual habits, gang membership, and the other ways youth may defy the norms of society. Chronic habitual suicide limits not only the quantity of life but its quality as well. It deprives the rest of us of the talents, the passion, and therefore the societal contributions that might have been made by the unfulfilled lives we are losing, often long before we have lost them. Such losses are immeasurable, and they slowly eat away at the edges of our civilization’s fabric.
The term
trimodal
has been applied to the time sequence of traumatic dying: immediate, early, and late deaths. An “immediate death” takes place within minutes of the injury. It includes more than half of all traumatic fatalities and is always the result of injury to the brain, the spinal cord, the heart, or a major blood vessel. The physiological process is either massive brain damage or exsanguination.
trimodal
has been applied to the time sequence of traumatic dying: immediate, early, and late deaths. An “immediate death” takes place within minutes of the injury. It includes more than half of all traumatic fatalities and is always the result of injury to the brain, the spinal cord, the heart, or a major blood vessel. The physiological process is either massive brain damage or exsanguination.
“Early death” takes place within the first few hours. The usual cause is injury to the head, the lungs, or the abdominal organs, with bleeding in those regions. Death may be due to brain injury, blood loss, or interference with breathing. Regardless of interval, in fact, about a third of all trauma deaths are due to brain damage and another third to bleeding. Although “immediate deaths” are beyond medical intervention, the lives of many patients who fall into the “early” category can be saved by prompt treatment. It is here that rapid transportation, well-trained trauma teams, and battle-ready emergency rooms make the critical difference. It has been estimated that 25,000 Americans die each year because such resources are not universally available. An example of the effectiveness of a quick delivery system is to be found in the lessons of this nation’s armed conflicts. In each of our last four major wars, an incremental change in medical know-how was accompanied by a decremental change in evacuation time. The result was a pattern of vastly improving mortality statistics from one war to the next.
“Late death” refers to those people who die days or weeks after the injury. Approximately 80 percent of those mortalities are caused by the complications of infection and failure of the lungs, kidneys, and liver. These people survive the initial blood loss or head trauma but often have sustained injuries to other organs, such as a perforated intestine, a ruptured spleen or liver, or perhaps a blunt injury to the lung. Not infrequently, surgery is required to stop bleeding, prevent peritonitis, or repair a damaged organ, perhaps removing it in the process. Many of these people, instead of recovering uneventfully, begin within a few days to develop fever, high white blood cell counts, and a tendency for some of their circulating blood volume to pool in inappropriate parts of the body, such as the blood vessels of the intestine, and thus be lost to the general circulation. All of these developments are characteristic of widespread infection, or sepsis, which becomes increasingly resistant to antibiotic and other drug treatment.
If the origin of the sepsis is an abscess or infected postoperative incision, surgical drainage will usually reverse the damage and allow the patient to recover. In many people, however, no drainable abscess can be found, so the symptoms progress. By the end of the first postinjury week, respiratory failure begins to appear in the form of pulmonary edema and pneumonialike processes, resulting in decreased oxygenation of the blood. The lung is one of the first targets of sepsis, but it is soon followed by the liver and the kidney. The entire evolving syndrome is thought to represent an inflammatory response to the presence in the blood of a variety of microbial and other invaders that generate toxic substances. These invaders may be bacteria, viruses, fungi, or even microscopic bits of dead tissue. The microbes, if they can be identified, are often found to originate in the urinary system, with the respiratory and gastrointestinal tracts following in frequency. In many cases, surgical wounds and skin are the sites of origin. In response to the presence of the circulating toxins, the lung and other organs seem to create and release certain chemical substances that have a deleterious effect on blood vessels, organs, and even cells, including the elements of the blood. The tissue cells become incapable of extracting sufficient oxygen from hemoglobin at about the same time that less hemoglobin is being brought to them by the reduced circulation. These events so much resemble the classical picture of cardiogenic or hypovolemic shock that their total effect is called septic shock. If septic shock does not respond to treatment, the vital organs fail one after the other.
The occurrence of septic shock is not restricted to subjects of trauma. It is seen in a variety of illnesses in which a patient’s defense mechanisms have become impaired. Not infrequently, in fact, it is the terminal event in such a spectrum of conditions as diabetes, cancer, pancreatitis, cirrhosis, and extensive burns, overwhelming its victims with a mortality rate in the range of 40 to 60 percent. Septic shock is the leading immediate cause of death in intensive care units in the United States, accounting for 100,000 to 200,000 deaths each year.
Once the lung has lost some of its ability to oxygenate the blood and the circulation is impaired by a generally depressed myocardium and pooling in the vessels of the gut, several organs begin to demonstrate the effects of the decreased nourishment. Cerebral function dwindles. The liver loses part of its ability to make some of the compounds the body needs and destroy those it does not. The liver failure compounds a concomitant depression of the immune system and the lessened production of infection-fighting substances. At the same time, the decreased blood flow to the kidney prevents proper filtering and results in an inadequate urinary output and gradually worsening uremia, which is a backup of poisonous products in the blood.
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