Old Patients, Ancient Questions

In the end, terminal geriatric patients need our candor and compassion – our humanity – rather than desperate heroics.  

Old age can best be described as awakening from an interesting dream before it ends. It’s irksome. Just when you thought you would have The Answer, it’s just out of reach. We all know that everyone dies, we just have trouble believing it will actually happen to us. There must be a meaning to life. When are we going to discover it? What about all my careful study and reading? Don’t they buy me a reprieve or get me at least a painless exit? “Sorry,” says the Universe, “no can do.” Damn it. I want a finite meaning to life and I want it now.

The premature awakening of the dream of our lives provides a thrill of pure terror. Will my sins follow me after death? Do consciousness and intentionality go all the way down with me intact? Or do we lose them relentlessly as we wither in varying degrees as we have seen in our own patients? There are very few good deaths. And this is mostly the fault of young physicians who beat the inevitably dying with plastic lines and useless drugs into eternity. The question is not what we are doing, but why? Who says that that person’s spirit is not on its way to being a taoist deity enthroned in a Buddhist heaven?

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Mathematicians are often accused of being Platonists because they all believe somewhere there is an ultimate proof – in some elegant form, in some alternate universe – which would explain truth, beauty and meaning. They search for the one equation that will solve the collapse of wave functions and eradicate the sticky Heisenberg measurement problem. In the same way, doctors believe that if they give enough epinephrine and pound hard enough, mental function as well as heartbeat will be restored. We somehow think our end-of-life “heroics” (or is that “hysterics”?) will return to terminal patients simple recognition, that abstract data will be taken into the body’s neurochemistry and physiological alchemy will magically produce normality again. “‘Tis a tale told by an idiot,” but we can’t help ourselves.

Physicians from the last half of the 20th century till now have been taught a fusion of scientific materialism mixed with a healthy dose of liberal egalitarianism viewing the patient more as a heart-lung preparation than a person. But this should not be so. Our real function should be to enrich each individual’s potential to succeed, not to aggrandize our diagnostic/therapeutic modalities. The real question is: Can we as healthcare professionals take as much pride in providing an excellent death as in a neuro-deficient save? Can our cosmology harmonize at all with our moral picture? Or are we positing a purely physical and purposeless universe inhabited only with evolutionary accidents? Are we attending to highly advanced mammals or individual people? At a certain point it’s hard to tell. Ask yourself if the rhythms of the monitors in the ICUs are the scientific sounds of a utilitarian Darwinism, justifying our own altruism? Or is there a true logical and moral abyss through which we function as guides to families, as the relatives pass through flamentia moenia mundi – the flaming ramparts of the world – to enter the terra incognita, “the undiscovered country from whose borne no traveler returns”?

I don’t mean to assault you with the vigor of a 17th century New England churchman, but rather to raise the issue of protecting our own psyche. We can make better treatment decisions when we can view each patient through the eyes of their family. I once worked at an ICU where the director insisted that there be multiple pictures of each patient around the bed, showing them in their younger and happier days. This wasn’t for the families. It was for the staff. We can get so caught up in the ventilatory volumes and fluid balance that we lose sight of the humans right in front of us.

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I always found that knowing something about the patient as a person made my decisions with their loved ones more credible, more real. It makes them realize that the health providers care about the person as well as the body. Simple acts like straightening the sheets and cleaning up the bodily fluids say more to the family than any carefully rehearsed speech. During the discussion of termination of various treatments, I’ve found that holding the patient’s hand helped me realize I was talking about and for an individual person. Again, it makes it real. It at least made me feel better. We were stopping treatment, but we never stopped caring.

I fully believe that there are only two things you need to help the terminal geriatric patient and their families. Those two things are candor and compassion. Euphemisms about death are both useless and disingenuous. You may be the first physician to truly bring real perspective as to anticipated results of various treatments. No cruelty, just honesty. They will thank you for it. This is the time for real empathy, not formulaic sympathy.

Thomas Jefferson reminds us that: “Honesty is the first chapter in the book of wisdom.” My experience is that the majority of people being forced to make decisions about their family members need and desperately want guidance. It’s almost universal in current American culture that the only thing we are all obligated to do, which is die, is never discussed. Families want help in dealing with saying goodbye. They want emotional absolution on the issue of allowing death, even when all meaningful existence is gone. They want your permission to feel good about what is happening. And as you provide guidance, you review and reflect on the process and find solace for yourself.     Ignorance of the process of death is universal in today’s world of hyper technology, hyper stimulated entertainment, hyper speed and hyper activity. Death runs completely opposite the hyper-reality of our present age. “Most men lead lives of quiet desperation,” wrote Thoreau. Recognize it in others and help them with solace and acceptance. And then – momento mori – recognize it in your self.

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As an old physician, which I am, do I have any insights for young physicians regarding geriatric care? Of course! I’m old and giving advice makes me think I still have a function. Without this raison d’être, a dignified death is preferable. First, there is an increasing unending line of us gray-hairs moving toward your department doors. Don’t slam those doors in our faces. Listen to the small complaints, remembering most things we have you can’t fix but you can certainly provide reassurance. Second, we are old, not necessarily deaf. There is no reason to double the decibel level or slow speech patterns to a crawl. Lastly, a warm blanket does feel good in Michigan in winter. As a matter of fact, they feel good in the summer as well because we keep the ED air conditioning set to levels where the health department would allow us to hang meat. Be kind to us. Blips on a monitor should never be mistaken for a meaningful existence.

On a closely related topic, I have some sad news. My 13-year-old golden retriever, Tucker, has died. You met him in the column a few months ago when I unkindly outed him as a Platonist. I can’t believe how many dog-loving readers wrote about my conversation with my dog. There must be a lot of us ER physician schizophrenics out there and I heard from most of you either by phone, email or telepathically.

Tucker went downhill quickly with two cancers. As he lost strength, lost the use of his hind legs and his pain increased, I knew I had to take him to the vet. He really was a good friend to me. Useless in all ways but a great friend. Could he protect the house? Not really. In fact, he would probably give any self-respecting burglar a tour of the silver, pointing out the Hester Bateman and the Paul Storr. But he thought he protected us and I didn’t have the heart to fire him. I’m not really sure why God made any other dogs than golden retrievers.

So I took him to the vet. They started the medication. And as he went to sleep, he looked up, licked my hand as if to say: “It’s okay, Dad. It’s been a great life.” Not a bad way to go, but God, I miss that dog.

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Qui me amat, emat et canem meum.