Authors: Sherwin B Nuland
How We Die (25 page)
All of this may be complicated by the destruction of cells lining the stomach and intestine, with resulting ulcerations and bleeding. Shock, kidney failure, and gastrointestinal bleeding are often the final events in people who die from the syndrome of posttraumatic failure of multiple organs. Stated another way, multiple organ failure is the end point of sepsis, and therefore the common end point for many patients whose primary process may be trauma or one of the more “natural” diseases of mankind. All the syndrome’s characteristics seem to be caused by the effects of the toxins on various organ systems of the body. The ultimate outcome for any individual patient is related to the number of organs that cannot withstand the assault. If three are involved, the mortality is close to 100 percent.
The playing out of the entire process usually takes two to three weeks, and sometimes longer. One of my patients, whose sepsis was the result of pancreatitis, lingered for months as all of us—surgeon, consulting physicians, anesthesiologists, resident staff, nurses, and technicians—called upon every diagnostic and therapeutic technique available in our university medical center to hold back the oncoming tidal wave of multiple organ failure, all to no avail.
The ordeal of patients who die of septic shock is indescribably difficult to watch. The unfolding of the ultimately lethal events follows a predictable pattern. First, there are the fever, rapid pulse, and respiratory distress, or at least some evidence of inadequate oxygenation found when the blood is analyzed. An endotracheal tube will be placed to aid the compromised respiration, but it soon becomes evident that no substantial benefit results. If the patient is not already sedated, his level of consciousness is beginning to fluctuate on its own. CT scans, ultrasounds, numerous blood analyses, and multiple cultures are done, all in an effort to find some remediable source of infection, often in vain. Consultants in groups converge around the cubicle, tapping and talking, and in general contributing to the increasing air of uncertainty. The patient is shuttled back and forth between the intensive care unit and the X-ray department as one or another imaging technique is called upon to seek out a pocket of pus or a locus of inflammation. Every transfer from bed to gurney and back becomes a logistical exercise in disentanglement of lines and wires. The spirits and plans of family and medical team change with each new set of laboratory reports, but only the good ones are shared with the anxious person in the bed, providing that individual can still fully comprehend their meaning. Antibiotics are started, changed, stopped in the hope of some treatable germ appearing in the bloodstream, and then restarted; in only about 50 percent of victims of multiple organ failure will a study of the blood yield microbes that will grow in a laboratory culture.
Various alterations in the blood elements appear, and the clotting mechanism may be inhibited, even to the point of spontaneous bleeding. The liver failure sometimes produces jaundice just as the kidney is showing its first serious evidence of progressive deterioration. Dialysis may be tried as a delaying action if there is still some hope of turning things around. By now, if not before, the anguished patient, providing he can still organize his thoughts, has begun to wonder whether enough can be done
for
him to justify what is being done
to
him. Although he cannot know it, his doctors are starting to wonder the same thing.
for
him to justify what is being done
to
him. Although he cannot know it, his doctors are starting to wonder the same thing.
And yet everyone continues on, because the battle is not yet lost. But all this time, something unnoticed has been happening—despite the best of intentions, the staff members have begun to separate themselves from the man whose life they are fighting to save. A process of depersonalization has set in. The patient is every day less a human being and more a complicated challenge in intensive care, testing the genius of some of the most brilliantly aggressive of the hospital’s clinical warriors. To most of the nurses and a few of the doctors who knew him before his slide into sepsis, there remains some of the person he was (or may have been), but to the consulting superspecialists who titrate the remaining molecular evidences of his dwindled vitality, he is a case, and a fascinating one at that. Doctors thirty years his junior call him by his first name. Better that, than to be called by the name of a disease or the number of a bed.
If the dying man has some luck left to him, he is by this time no longer aware of the drama in which he is the principal actor. He has gone from obtundation to minimal responsiveness or even coma, sometimes spontaneously as his organs fail and sometimes aided by narcotics and other medications. His family has gone from worry, to despair, and finally to hopelessness.
Not only the family but also the nurses and those doctors who have been with the dying man from the beginning gradually become affected by the heat of the crucible at the center of their losing campaign. They begin to question the very process by which they and the swarming consultants make treatment decisions or choose to pursue, with increasing desperation, yet another unpromising diagnostic clue. They torment themselves with the increasingly unavoidable perception that they are magnifying the suffering of a fellow human being in order to keep alive the slim hope of recovery; the most self-scrutinizing of the physicians confront that part of their motivation which is the excitement of solving the riddle and snatching up a glorious last-minute victory when the game seems all but unwinnable.
Their separation from the patient brings some of the members of the treatment team gradually closer to the family, as though a transfer of empathy takes place over the long weeks of the vigil. Especially near the end, the comfort that can no longer be perceived by the dying is bestowed upon those who have already begun to mourn. Rarely are there last words in intensive care units—whatever consolation is to be found must come from the warm embrace of a nurse, or the solace of a doctor’s words.
Finally, even those who have been unable to let go—even they—feel the relief that comes with the end of the long suffering. I have seen veteran nurses weep openly when an ICU patient dies; I have seen middle-aged surgeons turn their faces away so that young colleagues might not notice the tears. More than once, my voice, and my spirit, too, have cracked before I could utter the words that had to be said.
Of course, such scenes are not restricted to ICUs—they occur also in the general wards and in emergency rooms. Premature death by disease or unprovoked violence can be viewed dispassionately by only very few in the legions of those who care for the sick. But when the premature death is the result of self-destruction, it evokes a mood quite different from the aftermath of ordinary dying—that mood is not dispassion. In a book about the ways of death, the very word
suicide
appears as a discomfiting tangent. We seem to separate ourselves from the subject of self-murder in the same way that the suicide feels himself separated from the rest of us when he contemplates the fate he is about to choose. Alienated and alone, he is drawn to the grave because there seems no other place to go. For those left out and left behind, it is impossible to make sense of the thing.
suicide
appears as a discomfiting tangent. We seem to separate ourselves from the subject of self-murder in the same way that the suicide feels himself separated from the rest of us when he contemplates the fate he is about to choose. Alienated and alone, he is drawn to the grave because there seems no other place to go. For those left out and left behind, it is impossible to make sense of the thing.
I have seen my own attitude toward self-destruction reflected in the response of my eldest child. My wife and I had driven one hundred miles to the city where she was a college senior, because we both agreed that we should be with her when she heard the shocking news that one of her most admired friends had killed herself. As gently as we could, and at first without any of the few details available to us, we told our daughter what had happened. It was I who spoke, and I said it all in two or three short sentences. When I was finished, she stared at us unbelievingly for a moment as the tears began overflowing onto her suddenly flushed cheeks. And then, in an uncontrolled paroxysm of rage and loss, she burst out, “That stupid kid! How could she do such a thing?” And that was, after all, the point. How could she do it to her friends and to her family and to the rest of those who needed her? How could such a smart kid commit such a dumb act and be lost to us? There is no place for this kind of thing in an ordered world—it should never happen. Why, without asking any of us, would this beloved young woman just go ahead and take herself away?
Such things seem inexplicable to those who have known the suicide. But for the uninvolved medical personnel who first view the corpse, there is another factor to consider, which hinders compassion. Something about acute self-destruction is so puzzling to the vibrant mind of a man or woman whose life is devoted to fighting disease that it tends to diminish or even obliterate empathy. Medical bystanders, whether bewildered and frustrated by such an act, or angered by its futility, seem not to be much grieved at the corpse of a suicide. It has been my experience to see exceptions, but they are few. There may be emotional shock, even pity, but rarely the distress that comes with an unchosen death.
Taking one’s own life is almost always the wrong thing to do. There are two circumstances, however, in which that may not be so. Those two are the unendurable infirmities of a crippling old age and the final devastations of terminal disease. The nouns are not important in that last sentence—it is the adjectives that cry out for attention, for they are the very crux of the issue and will tolerate no compromise or “well, almosts”:
unendurable, crippling, final
, and
terminal
.
unendurable, crippling, final
, and
terminal
.
During his long lifetime, the great Roman orator Seneca gave much thought to old age:
I will not relinquish old age if it leaves my better part intact. But if it begins to shake my mind, if it destroys its faculties one by one, if it leaves me not life but breath, I will depart from the putrid or tottering edifice. I will not escape by death from disease so long as it may be healed, and leaves my mind unimpaired. I will not raise my hand against myself on account of pain, for so to die is to be conquered. But I know that if I must suffer without hope of relief, I will depart, not through fear of the pain itself, but because it prevents all for which I would live.
These words are so eminently sensible that few would disagree that suicide would appear to be among the options that the frail elderly should consider as the days grow more difficult, at least those among them who are not barred from doing so by their personal convictions. Perhaps the philosophy expressed by Seneca explains the fact that elderly white males take their own lives at a rate five times the national average. Is theirs not the “rational suicide” so strongly defended in journals of ethics and the op-ed pages of our daily newspapers?
Hardly so. The flaw in Seneca’s proposition is a striking example of the error that permeates virtually every one of the publicized discussions of modern-day attitudes toward suicide—a very large proportion of the elderly men and women who kill themselves do it because they suffer from quite remediable depression. With proper medication and therapy, most of them would be relieved of the cloud of oppressive despair that colors all reason gray, would then realize that the edifice topples not quite so much as thought, and that hope of relief is less hopeless than it seemed. I have more than once seen a suicidal old person emerge from depression, and rediscovered thereby a vibrant friend. When such men or women return to a less despondent vision of reality, their loneliness seems to them less stark and their pain more bearable because life has become interesting again and they realize that there are people who need them.
All of this is not to say that there are no situations in which Seneca’s words deserve heeding. But should this be so, the Roman’s doctrine would then deserve consultation, counsel, and the leavening influence of a long period of mature thought. A decision to end life must be as defensible to those whose respect we seek as it is to ourselves. Only when that criterion has been satisfied should anyone consider the finality of death.
Against such a standard, the suicide of Percy Bridgman was close to being irreproachable. Bridgman was a Harvard professor whose studies in high-pressure physics won him a Nobel Prize in 1946. At the age of seventy-nine and in the final stages of cancer, he continued to work until he could no longer do so. Living at his summer home in Randolph, New Hampshire, he completed the index to a seven-volume collection of his scientific works, sent it off to the Harvard University Press, and then shot himself on August 20, 1961, leaving a suicide note in which he summed up a controversy that has since embroiled an entire world of medical ethics: “It is not decent for Society to make a man do this to himself. Probably, this is the last day I will be able to do it myself.”
When he died, Bridgman seemed absolutely clear in his mind that he was making the right choice. He worked right up to the final day, tied up loose ends, and carried out his plan. I’m not certain how much consideration he gave to consulting others, but his decision had certainly not been kept a secret from friends and colleagues, because there is ample evidence of his having at least informed some of them in advance. He had become so sick that he felt it doubtful that he would much longer be capable of mustering up the strength to carry out his ironclad resolve.
In his final message, Bridgman deplored the necessity of performing his deed unaided. A colleague reported a conversation in which Bridgman said, “I would like to take advantage of the situation in which I find myself to establish a general principle; namely, that when the ultimate end is as inevitable as it now appears to be, the individual has a right to ask his doctor to end it for him.” If a single sentence were needed to epitomize the battle in which we are all now joined, you have just read it.
No contemporary discussion of suicide, at least not one written by a physician, can skirt the issue of the doctor’s role in assisting patients toward their mortality. The crucial word in this sentence is
patients
—not just people, but
patients
, specifically the patients of the doctor who contemplates the assisting. The guild of Hippocrates should not develop a new specialty of accoucheurs to the grave so that conscience-stricken oncologists, surgeons, and other physicians may refer to others those who wish to exit the planet. On the other hand, any degree of debate about physicians’ participation should be welcomed if it will bring out into the open a muted practice that has existed since Aesculapius was in swaddling clothes.
patients
—not just people, but
patients
, specifically the patients of the doctor who contemplates the assisting. The guild of Hippocrates should not develop a new specialty of accoucheurs to the grave so that conscience-stricken oncologists, surgeons, and other physicians may refer to others those who wish to exit the planet. On the other hand, any degree of debate about physicians’ participation should be welcomed if it will bring out into the open a muted practice that has existed since Aesculapius was in swaddling clothes.
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