On Old Age and Death II

“… life is such a brief span at the longest, one should put self and self-interest on one side. In the first place, one should put duty to the Master. How best can I work for good of others should be the supreme question.” -Harvey Cushing (father of modern neurosurgery, 1869-1938)

In many–even most circumstances–it falls to the physician to aid his/her patient to deal with the inevitable condition of mankind. Here, we will deal with what medical literature has contributed–or failed to do—over the ages. That literature is replete with motivating, lamenting, rebellious, and existential, philosophies dating from 700 BCE. It contains wisdom and foolishness, truth and superstition, science and witchcraft. At its core, such writing deals with aging—the proverbial human sentence that ultimately commands each of us to be born, to live, to age, to decay, and to die. Contemplative and hopeful literature has beauty and conveys hope that resists death but is often at odds with even the more primitive medical lore. But all the literature—medical, poetic, and philosophical, thinking—struggles to come to terms with life, decay, and inevitable death.
Life, in fact, is a continual struggle against decay or immediate physical attacks on an animal’s sense of safety, of threats, and of natural decay. The poet put it well:

“Nature’s first green is gold,
Her hardest hue to hold,
Her early leaf’s a flower:
But only so for an hour.
Then leaf subsides to leaf.
So, Eden sank to grief,
So dawn goes down to day,
Nothing gold can stay.”
-Robert Frost [1874-1973]

Classical literature has sought to come to grips with and even to soften the impact of decay and death.

“It is easier to find men who will volunteer to die, than to find those who are willing to endure pain with patience.”
-Julius Caesar

“It is old age [referring to decay], rather than death, that is to be contrasted with life. Old age is life’s parody, whereas death transforms life into a destiny; in a way, it preserves it by giving it the absolute dimension. Death does away with time.”
-Simon de Beauvoir, The Coming of Age [La Vieillesse], 1970

“’Tis the condition of your creation; death is a part of you, and whilst you endeavour to evade it, you evade yourselves… Give place to others, as others have given place to you.”
– Michel de Montaigne, 16th century

In this modern age–most of us die of complications of chronic incurable diseases. Death is very much the territory of doctors. Legally, nobody is dying or dead until a doctor says so; and an increasing number of people die in intensive care units.
“I’m running a warehouse for the dying,” said an intensive care doctor quoted in an essay on death by the surgeon Atul Gawande. An unhappy statistic is that only about a fifth of patients emerge alive from American intensive care units.
Modern medicine encouraged the decay of traditional means of making sense of death and dying in exchange for an implied but false promise of immortality. Gawande said, “In the past few decades, medical science has rendered obsolete centuries of experience, tradition, and language about our mortality, and created a new difficulty for mankind: how [and when] to die.”
Siddhartha Mukherjee, an oncologist, in his Pulitzer Prize winning book on cancer quoted a ward nurse who said: “The resistance to providing palliative care to patients was so deep that doctors would not look us in the eye when we recommended that they stop their efforts to save lives and start saving dignity instead… doctors were allergic to the smell of death. Death meant failure, defeat–their death, the death of medicine, the death of oncology.”
We doctors should take a cue from the philosophers and assist our patients by dealing with the truth:

“There is no cure for birth and death save to enjoy the interval.”
-Jorge Augustín Nicolás Ruiz de Santillana, [1863-1952] aka George Santayana

“Some people die at 25 and aren’t buried until 75.”
-Benjamin Franklin

The fine line between maintaining hope and offering a reality check is tricky territory.
The question then becomes, which is more important: knowing the reality of your situation or maintaining hope? Is decoding how you want to die, after all, just about control?
-Dr. John Marshall, oncologist, and director of Georgetown’s Ruesch Center for the Cure of Gastrointestinal Cancers

We ought not practice medicine simply to cure a new ailment in an elderly or cancer-ridden person, nor to satisfy a wallet check [after all, insurance companies approve such treatments, trusting the physician, don’t they?]. We would do well to teach what George Santayana taught, “If life has been joyful, productive, and essentially happy, then death should not be feared. If life has been grim, dreary, and fearful, be glad that it is over.” A wise early native American war chief emphasized much the same thing,

“When your time comes to die, be not like those whose hearts are filled with fear of death, so that when their time comes, they weep and pray for a little more time to live their lives over again in a different way. Sing your death song, and die like a hero going home.”

I learned my lessons the hard way. During my general surgery residency, I did a mandatory three-month service on the oncology surgical service. I was still in my first year of surgery and determined to show well among my professors and fellow interns with whom I competed. In the middle of a long night of caring for surgical cases pouring in from the Emergency Department, I was called to see a dying man.

He was elderly, emaciated, and had parchment skin. He was in agony, having difficulty breathing, and was not going to survive through the night. As I saw it, the problem was simple. He had bilateral pneumonia; and the causative bacteria was one susceptible to almost every antibiotic including simple penicillin G, the cheapest and most reliable medication for that infection in the entire world. It was an antibiotic against which the old gentleman’s pneumococcal infection was effective.

I made him comfortable, started an IV and gave him a hefty dose of the curative antibiotic intravenously. As expected, the effect was nothing short of miraculous. On rounds the next morning, the nice elderly retiree was alert, entirely compos mentis, had clear lungs, and I patted myself on the back and said to myself, “What a good boy am I!”

Oh, and he was writhing in tormenting agony.

I expected the waiting family to shower me with “Attaboys” and great gratitude which I would acknowledge in my usual humble way.

Instead, the patient’s children were crying and staring daggers at me.

I thought, “Well, I guess no good turn goes unpunished, and some people just can’t be pleased.”

I was too new and too young to be able to comprehend why and to what degree they were angry with me. The eldest son served as spokesman for the family and said,

“How could you?? This was Dad’s chance to pass on quietly and painlessly. How cruel can you be, young man? Who can say how long he will have to live with his terrible pain?”

I could not come up with an appropriate rejoinder; so, I retreated and waited for the attending surgeon to come and bring me some relief and to mix some praise into the torrent of enmity coming my way.

He examined the patient, shook his head and descended on me.

“Did you even check this poor man’s history. He has squamous cell carcinoma of the mandible and has had multiple unsuccessful operations. His jawbone pain is untreatable except with IV opiods. His only recourse will be death. He developed pneumonia which was going to be the answer, but you robbed him of that. I don’t suppose you have ever heard it called ‘the old man’s friend’? I didn’t think so. I have some advice for you… ‘next time think’.”

Much chagrined, I went back to the very upset family and apologized; it may seem strange to have a doctor apologize for saving one’s relative’s life; but they were forgiving of my youth and misunderstanding. It was an absolute lesson learned, and I never made the mistake again.

The seven decades/stages of life have been characterized as:
1. Infant—mewling and puking in the nurse’s arms.
2. Whining schoolboy—creeping like a snail unwillingly to school
3. The lover—sighing like a furnace with a woeful ballad made for his mistress’s eyebrow.
4. The Soldier—seeking the bubble reputation even in the cannon’s mouth.
5. Middle age—the justice in fair round belly with good capon lined.
6. Late middle age—his big manly voice, turning toward childish treble, pipes and whistles in his sound.
7. The last scene—second childishness and mere oblivion, sans teeth, sans eyes, sans taste, sans everything.
-Shakespeare, As you like It.

“Life is hard. Then you die. Then they throw dirt in your face. Then the worms eat you. Be grateful it happens in that order.”
-David Gerrold

I chose to use a pseudonym for personal reasons. I’m a retired neurosurgeon living in a rural paradise and am at rest from the turbulent life of my profession. I lived in an era when resident trainees worked 120 hours a week–a form of bondage no longer permitted by law. I served as a Navy Seabee general surgeon during the unpleasantness in Viet Nam, and spent the remainder of my ten-year service as a neurosurgeon in a major naval regional medical center. I’ve lived in every section of the country, saw all the inhumanity of man to man, practiced in private settings large and small, the military, academia, and as a medical humanitarian in the Third World.