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REFLECTIONS ON MEDICINE

When the Time for Heroics Has Passed

ROBERT U. MASSEY, M.D.

Many have studied to exasperate the ways of Death, but fewer hours have been spent to soften that necessity.

Sir Thomas Browne

     Physicians have never quite known how to behave at the bedside of their dying patients. It may even have been harder 30 years ago before our amazing life-extending (or dying-extending) technologies were available to keep us busy. I knew a distinguished endocrinologist who, when his patient took her last breath as he stood by, seemed embarrassed, crossed himself, bowed slightly, and backed out of the room. Sometimes in those far off days we would call for an epinephrin-filled syringe with a long needle and aim it at the precordium, empty it, and wait. In my experience nothing ever happened, but we could leave feeling that we had done our best.

     Now hospital deaths are often wild, a confusion of unfeeling, but well-meaning, noisy busyness in the ICU, nurses and housestaff standing by or manipulating tubes, defibrillators, respirators, or just watching the monitor as someone forcibly and rhythmically compresses the chest. Hardly the euthanasia, the peaceful departure, the good death that the ancients wished for themselves and their families. Daniel Callahan wrote of the "wild death," earlier described by Philippe Ariès, and now so common in our hospitals:

It is wild not simply because it is out of control and terrorizing in its modern incarnation, but also because, in the name of combating mortality, it has managed simultaneously to subvert the institution of medicine, which cannot overcome mortality, and the morality of human decisions about life and death, which should not have to bear the burden of omni-responsibility.1

Callahan hardly intended to deny anyone the right to choose the wild death, "… technological brinkmanship without restraint, aiming to go as far as medical aggressiveness


ROBERT U. MASSEY, M.D., Professor Emeritus, Division of Humanistic Studies, Department of Community Medicine and Health Care, University of Connecticut School of Medicine, Farmington.

will allow," but that he should know and be prepared to accept "risking a terrible death—a risk for himself but also for those who must care for him."2

     In discussions with older men and women, those mostly well beyond the Psalmist's three score and ten, I have found an almost universal fear—even terror—that instead of that peaceful death that nature so often provides, they will be pummeled by EMTs, delivered to the ER, and then rolled away to the ICU with absolutely no choice in the matter, and spouses or children powerless, or not aggressive enough, to intercede. Over and over I hear of living wills ignored, especially when they could not be produced on the spot. One elderly man thought he might have DNR tattooed on his forehead! More than this, many are concerned that in the helplessness of their final illness they will be subtly urged by well-meaning families and physicians to have just one more round of chemotherapy or radiation, or will be cheated out of a quiet death from pneumonia. I recall a wife and her two sons, both ministers, blocking the hospital room doorway of her husband and their father, near death from leukemia, for whose pneumonia a resident had, not inappropriately, ordered antibiotics to be given. They won the standoff, but only because they were able to reach the patient's physician and friend by phone. The patient died a peaceful death 24 hours later, and the resident sulked.

     Leon Kass writes that our urge to medicalize death is hubris and reminds us of the tragic fate awaiting those who succumb to this all-too-human fault. "We do not understand that the project for the conquest of death leads only to dehumanization, that any attempt to gain the tree of life by means of the tree of knowledge leads inevitably to the hemlock.…" and that "the victors live long enough to finish life demented and without choice." He concludes:

The present crisis that leads some to press for active euthanasia is really an opportunity to learn the limits of the medicalization of life and death and to recover an appreciation of living with and against mortality. It is an opportunity to remember and affirm that there remains a residual human wholeness—however precarious—that

 


can be cared for in the face of incurable and terminal illness. Should we cave in, should we choose to become technical dispensers of death, we will not only be abandoning our loved ones and our duty to care; we will exacerbate the worst tendencies of modern life, embracing technicism and so-called humaneness where encouragement and humanity are both required and sorely lacking.3

     Over 170 years ago, a medical student at Göttingen by the name of Carl Friedrich Heinrich Marx wrote his doctoral thesis, De euthanasia medica, "Medical Euthanasia,"4 by which he meant, not the active euthanasia, the killing that many are demanding as an alternative to a wild medicalized death, but rather the passive good death, the peaceful death of skillful palliation that today defines hospice care. Almost two centuries ago this newly minted Med. et Chir. Dr. from his ancient university in Brunswick reminded his fellow academics of that "great Englishman," Francis Bacon, who had written 200 years earlier urging physicians "to stay with the patient after he is given up,…" and "to acquire the skill and to bestow the attention whereby the dying may pass more easily and quietly out of life."

     Marx's recommendations were strikingly similar to the principles of hospice care today; he would have understood, as perhaps would Bacon, the notion of physician assisted living (PAL) during life's final exit. "Most physicians," he wrote, "once they see the expected result of their treatment to be wanting,… start to lose interest themselves." He even mentions a program at Heidelberg headed by a Prof. Mai, and funded by Amalia, Duchess of Baden, that provided training to women attendants in caring for the sick and the terminally ill. Marx recommended that these caregivers be "considerate, watchful, quiet, clean, free of prejudice toward people,… and adhere to the doctor's orders with greatest obedience." He described the care of bedsores, and that the "doctor will with his own eyes repeatedly search for" them.

     Marx asked, "What good will it do the incurable patient to apply dangerous and dubious therapeutic measures? The entire plan of treatment will here confine itself within `symptomatic and palliative medication.'" He even reminded his physician colleagues to see that the patient's dry tongue and pharynx be moistened. He urged "soothing, soporific, sedative, analgesic" medicines, and noted

 

 

that "… narcotics are of enormous help." But later he added the essential caveat, "… and least of all should he be permitted (italics mine), prompted either by other people's requests or by his own sense of mercy, to end the patient's pitiful condition by purposely and deliberately hastening death. How can it be permitted that he who is by law required to preserve life be the originator of, or partner in, its destruction?"

     In Marx's brief thesis, written in 1826 upon his being admitted to the faculty at Göttingen, we can find all the principles of hospice care and of physician care at the end of life embodied in the PAL program. Nothing new here. But even he was not their originator; we find them not only in Bacon, but in the ancients—Pliny, Cicero, Seneca, the Bible. They are imbedded somehow in our nature, and even, as Lewis Thomas once suggested in nature itself: why else the endorphins? Concerning them he wrote, "If I had to design an ecosystem in which creatures had to live off each other and in which dying was an indispensable part of living, I could not think of a better way to manage."

     But when endorphins are not enough for the kinds of nonviolent, prolonged deaths that we often produce and must endure, we have the means and the inherent mercy to ease the passage. We should pay more attention to the business of dying. My Harrison's Principles of Internal Medicine devotes one and one half pages out of 2,044 to this matter, but it does address the physician's role: "First of all, the patient must be given an opportunity to speak to his physician and to ask questions."

     This is what the PAL program as a part of the advanced directive is all about. It frees patients who are prepared to plan for the inevitable event to consider the options, discuss them with their physicians and families, choose, and then say with Seneca: "I am ready for death, hence I may enjoy life."

REFERENCES

1.Callahan D: A Troubled Dream of Life: Living with Mortality,

New York: Simon & Schuster; 1993:90.

2.Callahan D, p. 206

3.Kass LR: Death with dignity and the sanctity of life, In: Kogan BS, ed: A Time to Be Born and a Time to Die, New York: Aldine de Gruyter: 1991; 117-45, p. 141.

4.Cane W: "Medical euthanasia": A paper published in Latin in 1826, Translated and reintroduced to the medical profession, J Hist Med Allied Sci 1952; 7:401-16.


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