Letting Go
A few experiences in the last week or two have reminded me of the importance of Peter Safar’s Laws for the Navigation of Life:
Law 20. Death is not the enemy but occasionally needs help with timing.
Sometimes some of us seem to forget that for all of us the time will come one day.
Death is an inescapable fact of life. Really when it comes to death, our job as doctors is to help ensure that people die in the ‘right’ order – not too soon, not too late. Sometimes this means we shouldn’t intubate, we shouldn’t place central lines, we shouldn’t insert vascaths and start renal replacement therapy, we shouldn’t start myriad infusions of inotropes and vasopressors, and we shouldn’t take the patient to the operating theatre. Recognising that the time is right for a particular patient can save a lot of distress and suffering – for the patient, the patient’s family and friends, as well as the medical and nursing staff caring for the patient.
When this goes wrong, sometimes the only antidote is black humo(u)r. Here are some of the worst antidotes I know:
Q. What is the difference between a Rottweiler and an Oncologist?
A. After you’re dead, the Rottweiler will let you go.
Q. How can you recognise a Hematolgist?
A. Look for the scorch marks on his hands from trying to hold back the coffin as it goes into the crematorium.
The oncologist scratched his head. After 19 cycles of chemotherapy, his patient still wasn’t getting better. In fact he was worse.
“Let’s try one more cycle of chemotherapy”, he said.
After the 20th cycle the patient went to see the Oncologist again. The patient was so tired and listless he couldn’t speak. His skin and eyes were yellow, he was unable to eat or defecate, his face was puffy and he couldn’t pass urine.
The Oncologist pondered his options. “I think we should try one more cycle of chemotherapy”, he said.
The patient died. The Oncologist left the funeral perplexed. “Maybe we gave up too soon”, he muttered to himself. “Maybe one more cycle of chemotherapy will bring him back”.
The Oncologist dug into the freshly turned soil with his shovel. Finally he reached the coffin. With sweat dripping from his brow he forced the coffin door open. Inside was empty. “What? Where is my patient?”, the Oncologist exclaimed. He frantically searched inside the coffin and finally found a note.
The note said, “Gone for dialysis”.
Hat tips to all those who have shared their morbid senses of humo(u)r with me over the years. And to all the oncologists, hematologists and nephrologists out there – no hard feelings – you’re still the among the smartest, most dedicated and caring docs out there.
After so many years as designated death bed vigil “personnel”, this post hit me like a ton of bricks. Even with a jovial twist it’s a great post meriting serious reply. I have much to say on topic but sort of brain dead during the holidaze to answer in philosophical detail. Needless to say I’m all for letting go. Nothing more horrific then seeing a shell of nothing withering away whilst family holds on to non-existent hope. Life…no one makes it out alive. No escape so buckle up and enjoy the ride while it lasts. Advance life directives are imperative as Doctor’s hands tied helping with termination of medical care when others sit around fiddling their thumbs. I also have a big problem with people having all these prerequisites on receiving or not receiving care. WTF are they in the hospital for? Their health?
You get the ones with “no blood” tattoos, some don’t want hair cut off, some want a Bible toter on speed dial, etc, etc…as if this should be the Doctors primary concern?! I say if you want a particular Doctor to baby-sit all your quirks don’t go into a public Emergency Room. Hire your own Physician like Michael Jackson did–oops probably not best example or like the Pope does. If you don’t, chances are you may get Dr. Kevorkian who’s doing time for assisted “suicide”. If Dr. Kevorkian had gone around as an “death angel of mercy” then he would be a psycho but if he was called upon for end of life assistance, he was doing what patient asked for. WTF do they think morphine drip for pain management is? Same sh*t as if you would call Kevorkian. It’s all silly if you ask me. I’m all for bringing the half-dead home to have their final days with dignity if that’s what they want . I’m also or for helping speed creeping death in a hospital bed or home if that’s what they want. Crap let them smoke, drink and party…not like they are going to make it out alive.
Thanks for the comment Francesca.
The issue of 'Letting Go' is a very personal one, and different people have widely varying views (as we all know). I'm all for 'Letting Go' when the time is right. But I also not for giving up when there is a battle that can be one. I can also respect patients who, because of their 'warrior spirit' or for whatever reason, want to go 'down fighting', although from my standpoint this isn't usually a good idea.
I also take your point, that while we in hospitals endeavo(u)r to be patient-centered, the bottom line is that if you come to hospital, you will get hospital care. The onus is on us, however, to help decide when the hospital is no longer the place to be. Hospices and the hospice movement are light years ahead of us in terms of helping the dying.
It is hard to achieve dignity in the act of dying – perhaps Sherwin Nuland is right: “The dignity we seek in dying must be found in the dignity with which we have lived our lives. Ars moriendi is ars vivendi: the art of dying is the art of living.” (from http://www.yalealumnimagazine.com/issues/00_10/...). Knowing more about our patients lives before they became gravely ill may help us help them have a dignified end, but is much harder on us emotionally.
Like you I think advanced directives are important. Perhaps more important is discussing with your loved ones what you, and they, want when the time comes, because it will come…
Thanks for the comment Francesca.
The issue of 'Letting Go' is a very personal one, and different people have widely varying views (as we all know). I'm all for 'Letting Go' when the time is right. But I also not for giving up when there is a battle that can be won. I can also respect patients who, because of their 'warrior spirit' or for whatever reason, want to go 'down fighting', although from my standpoint this isn't usually a good idea.
I also take your point, that while we in hospitals endeavo(u)r to be patient-centered, the bottom line is that if you come to hospital, you will get hospital care. The onus is on us, however, to help decide when the hospital is no longer the place to be. Hospices and the hospice movement are light years ahead of us in terms of helping the dying (see http://www.nytimes.com/2009/12/01/health/01brod...).
It is hard to achieve dignity in the act of dying – perhaps Sherwin Nuland is right: “The dignity we seek in dying must be found in the dignity with which we have lived our lives. Ars moriendi is ars vivendi: the art of dying is the art of living.” (from http://www.yalealumnimagazine.com/issues/00_10/...). Knowing more about our patients lives before they became gravely ill may help us help them have a dignified end, but is much harder on us emotionally.
Like you I think advanced directives are important. Perhaps more important is discussing with your loved ones what you, and they, want when the time comes, because it will come…