It is challenging to write about death, but a blog on aging would not be complete without discussing it. I do not claim to be an expert on death and dying, and the following thoughts are from a composite of many people’s ideas including my own.
When I started medical school at age 21, I had virtually no experience with death. I had never been to a funeral or seen a dead person. In retrospect, it seems shocking, but death is so sanitized in this country, it is kept largely out of sight. My grandfather had died, but he lived 3,000 miles away.
In my first year anatomy class, I helped to dissect a cadaver, but this embalmed, sinewy being hardly seemed to have ever been alive. Our focus was on learning the muscles, organs and bones. There wasn’t much thought given to whom this person was.
My first direct encounter with the death was on a Saturday morning when as an intern, (first training year after medical school) I admitted a lady to the hospital with severe congestive heart failure. She was terribly sick with extreme shortness of breath, severe edema in both legs and great anxiety from her breathlessness. Congestive heart failure is the result of damage to the heart muscle from any cause. The weakened muscle does not adequately pump the blood forward, and it backs up into the lungs and causes edema elsewhere. The patient was in severe distress, and since my supervising resident had gone home for the weekend, I called the senior resident on-call to come and help me decide what to do. Nowadays, there are powerful diuretics that can help the patient’s kidneys drain the excess fluid from her body and allow her heart to compensate, but the diuretics that were available at the time were relatively weak and ineffective to treat an emergency.
I was delighted with the resident who answered the call. He was someone that I looked up to and admired. He assessed the patient and thought that there was little that could be done other than to give her morphine which would allay her anxiety and sometimes improves congestive heart failure, potentially easing her breathing, Then he raced off to see other patients who needed him saying that I should do the best that I could. I was dismayed having been left on my own with this very sick patient. I gave her such diuretics as we had and administered morphine in a modest dose, which didn’t touch her symptoms. So, I gave her more morphine, hoping to find a dose that would make her more comfortable. After her third dose of morphine, her breathing slowed, much to her and my relief, but then she stopped breathing and died.
It was a shocking introduction to dying, and for a long time, I carried the belief that I was the cause of it, either because of my lack of knowledge of what else to do or because of giving too much morphine. After many years, I realized that what I did was an act of empathy. The lady was on the cusp of dying when she came to the hospital, and, in the absence of an effective treatment, what I did was to relieve her distress. At that time, CPR had recently come into existence, and virtually no one in a hospital was allowed to die without going through CPR as his/her terminal event. Trainees were taught that this was standard practice. Even though it was usually unsuccessful, it was done routinely. The health care culture operated on the principle that there is always something else that can be done. Death is a defeat.
In the mid 1960s, a different approach to the treatment of dying patients began to emerge; the concept of hospice was introduced in the United States. It was originated in England by a physician, Dame Cecily Saunders, and in 1963, she came to the US and started the first hospice unit in this country affiliated with Yale Medical School. In 1969, Elizabeth Kubler-Ross published her book “On Death and Dying”, which became a best seller, and in it she made a plea for allowing people die at home. She also testified to Congress that…
“We live in a very particular death-denying society. We isolate both the dying and the old, and it serves a purpose. They are reminders of our own mortality. We should not institutionalize people. We can give families more help with home care and visiting nurses, and so give the families and the patients the spiritual, emotional, and financial help in order to facilitate the final care at home.”
In 1979, congress funded an experiment with 26 hospices. Since then, the hospice movement has gradually spread throughout the country. Hospice operates on the principle that as one nears the end of life that the focus should shift from curative medicine to supportive care and comfort, including pain management, nutrition, counseling and facilitating the dying person’s last wishes. It has proven to be cost-effective and more satisfying for patients and family. To enter a hospice program and have it paid for by Medicare, one needs to discontinue curative treatments like cancer chemotherapy and have a life expectancy of six months or less.
Palliative care, a specialty that has grown quickly in the last decade, has a similar focus on comfort and quality of life improvement for patients with severe chronic diseases, but it allows simultaneous disease treatment and doesn’t have any time requirement.
So slowly the practice of medicine has incorporated practices and expertise that can make the end of life more comfortable and appropriate. Pain can almost always be managed, and the dying patient is generally more comfortable in familiar surroundings. Surveys indicate that up to 80% of people say they would prefer to die at home. So from my days as a trainee 50 years ago to now, we are slowly starting to realize as a society that there is a time when persisting with medical treatment really doesn’t do patients a service. We can’t escape death but we can make the time before we die more manageable.