“It is true that I am carrying out various methods of treatment recommended by doctors and dentists in the hope of dying in the remote future in perfect health.” -George Santayana
It seems to me that there are two ways to approach the oncoming end we all must face. The first is to accept the inevitable and to make a strong final effort to find happiness in some way, by any reasonable way possible. Money, power, fame, and erudition, will not necessarily bring happiness, especially as we have intimations of the end. That fact was made clear to me by reading a statement by Abd Ar Rahman III as he reached old age. He was the Umayyad Emir of Córdoba from 912 to 929 CE, serving as its first caliph until his death. Abd al-Rahman won the laqab (sobriquet) al-Nāṣir li-Dīn Allāh [Arabic: the Defender of God’s Faith].
He proudly capsulized his long and successful life:
As great as the man’s exploits and accomplishments were, he could only find fourteen days of pure and genuine happiness. Take note of the fact that Abd Ar Rahman III nowhere mentions anything about his family. Perhaps his paucity of enjoyable days–especially his last days, about which he was writing–can be attributed to that sad fact.
The obvious conclusion is that one should prepare for the inevitable day. An important way to do that is to cultivate and nurture family relationships be they biological or sociological, nuclear or extended. Long associations foster mutual memories which provide the fodder for thought and agreeable conversation among friends and family as life wanes.
The second option for coping with approaching death is to be less docile and submissive. As and example, Dylan Thomas asked his dying father to fight rather than to accept his destiny of decline and decay meekly.
“Do not go gentle into that good night,
Old age should burn and rave at close of day.
Rage, rage against the dying light.”
I presume Thomas meant for his father to do something even if he did not feel like it. In my experience, that can only go so far. Dying people need to rest, and most of the ones I attended looked forward to death as a time for them to obtain genuine and full rest. I suggest forethought and planning if the option of not going quietly into the night is chosen. Remember that in Christian tradition, the seven heavenly virtues combine the four cardinal virtues of prudence, justice, temperance, and fortitude with the three theological virtues of faith, hope, and charity. I see no issue for any of the world’s great religions to adopt such qualities and to reflect on them among family and friends as the darkness closes in.
Judaism emphasizes justice, truth, peace, love, compassion, humility, charity, ethical speech, and self-respect. Islamic virtues include kindness–to both people and animals–charity, forgiveness, honesty, patience, justice, respecting parents and elders, keeping promises, and controlling one’s anger, love of God and those God loves, love of his messenger (Muhammad) and of believers. Buddhist realization of the good life includes its widely promoted list of virtues: the Pāramitās [perfections], Dāna [generosity], Sīla [proper conduct], Nekkhamma [renunciation], Paññā [wisdom], Viriya [energy], Khanti [patience], Sacca [honesty], Adhiṭṭhāna [determination], Mettā [Good-Will], and Upekkhā [equanimity].
In my practice and life I have had occasion to be responsible for the care, and have attended the needs of individuals from all those religious affiliations, black, white, yellow, and mixed races, and genders. They all needed the same thing: for me and for family and friends to ease them into eternity or the rest of oblivion, according to their beliefs. I must say that during my times of meeting such disparate people with their diverse beliefs, I never met a person who did not belief in an afterlife replete with associations with family and friends; and that was a source of comfort for the dying who believed in God and religion. My atheist patients found solace in the last days and hours of having family and friends hold their hands and speaking of pleasant memories, of things learned, and of places of mutual travel.
Each of the religionists and even the atheists seemed to respond to the message of the Twenty-third Psalm and enjoyed reciting it verbatim with me:
“The Lord is my shepherd; I shall not want.
He maketh me to lie down in green pastures: he leadeth me beside the still waters.
He restoreth my soul: he leadeth me in the paths of righteousness for his name’s sake.
A Psalm of David
Even for the irreligious, that psalm resonates and comforts as the termination of life looms close; and it gives comfort. I spent too many nights in hospitals between 2011 and 2019 trying to sleep with terrible pain and the genuine fear that I might well slough my mortal coil that night. I was one of those who did not relish going quietly into the night; I had things to do, places to be, and a family to nurture. I recited poems, told myself stories about my past, and forced myself to hold on to cherished memories. Some of those times I could not bring up the plots of books or the beauty and flow of poetry. Then, I gave myself emotional relief by reciting the 23rd Psalm to the mineral fiber ceiling tiles in the dark.
Permit me to tell you a story of a patient I had the privilege of knowing and treating for a fatal illness. I will keep her name private, even though she died more than five decades ago, out of respect and in compliance with the law. I will call her Joyce.
I met Joyce on my first day of active duty during the Viet Nam war era. I was drafted to be a general surgeon in the Navy, and I knew next to nothing about the daily life of such an officer. Joyce worked in the base exchange where I needed to buy my uniforms, shoes, and insigniae of rank. Joyce was a beautiful Black woman with a sense of humor, and she was used to seeing the green-horn doctors flounder around to get ready for signing in at the base administration during the upcoming week. I told her what I needed; she smiled; and she led me to an area of used uniforms because I had almost no money and needed to be thrifty. I got my uniform stuff, and my fellow doctors got theirs. We presented ourselves to the hospital master chief three days later.
I thought the man would have a stroke because he convulsed with laughter. He gave the six of us looks that only a seasoned senior enlisted person reserves for green young officers. When he regained his composure and quickly pointed out that my chosen uniforms were for a third class petty officer, and my cap was for a commander or above. At least, I had three uniforms and shoes in the correct colors: marine maroon (~brown), Navy blue, and dress white.
With an Ozymandias scowl “whose frown, and wrinkled lip, and sneer of cold command, said without speaking, “My name is Ozymandias, King of Kings; look on my works, ye mighty, and despair!” Master Chief O’Reilly led us back to the Exchange in an uncomfortable armored APC [Armored Personnel Carrier].
He gave Joyce a knowing frown, which made her laugh, then led her and us back to the new uniform section and got us promptly and properly outfitted. At that moment, I became a bona fide member of the brown shoe navy.
As we walked out of the store, I passed Joyce who maintained a stone-statue face. But when I walked past her, she gave me a gentle pat on the bottom as an insult, and a broad toothed grin as a reward. I had been had, and I enjoyed it.
On one of the worst days of my career, Joyce came to my clinic office and told me that she had a breast mass, and that she had maybe neglected it a little bit. She was partly right; she did indeed have a breast mass, one in each breast, and even on physical exam, they were obviously malignant. She also had bilateral axillary lymph nodes which were enlarged and hard—also highly likely to be cancerous metastases. The masses were apparent on chest x-rays, which was a good thing because CT scans and mammography were not available to the public then.
I was of the opinion that the best diagnostic and treatment modum was surgery. The only procedure available in those benighted days–now thankfully gone–was bilateral radical mastectomy with extensive bilateral lymphadenectomies. I explained the disease and its terrible reputation, the planned operation with all its terrible adverse possibilities, and the plan for the future. She and her husband wept. He was a burly, heavily muscled man with rough workman’s hands and arms with shrapnel scars. They held each other and cried out their woes as I stood helplessly by.
The following day, I did the six hour surgery which involved taking off the involved breast skin, the muscles, connective tissue, nerves, veins, and arteries on both sides and spent most of the time denuding her arm pits of lymphatic vessels and nodes. I closed the wounds leaving her with a flaccid skinny chest that any woman would hate. Having been forewarned, that lovely, stoical, woman expressed her condolences to me for having had to do such a dreadful thing. Every segment of tissue removed had cancerous tissue or nodes. The prognosis was all but hopeless, but I could not tell her that yet. I had to give her some time to feel alive.
Her metastases spread and enlarged throughout most of her body. A whole body x-ray workup revealed tumors in every long bone, her cranium, her vertebrae, and her pelvis. With very low expectations, I treated her with chemotherapy, such as it was. She received methotrexate which at best had proven useful for palliation of some childhood acute leukemias and for a rare type of metastatic cancer called choriocarcinoma. Her tumors were too wide spread to make radiation therapy feasible. She had all the side effects of her tumors and treatments including the relatively recently available drugs to reduce side effects, like colony-stimulating factors, chemoprotective agents such as dexrazoxane and amifostine, and anti-emetics to reduce nausea and vomiting which Joyce had with a vengeance. Adjuvant therapy to kill local pockets of cells helped a little, but our enemy was too powerful and too many, and it kept going and going inexorably.
Breast cancer is driven by estrogen, and then, there were no anticancer antiestrogen drugs. The only thing to do was to perform an oophorectomy [bilateral excision of the ovaries]. We all had another good cry.
Joyce had pain. Soon she had pain she could not bear. I gave her Tylenol for a few doses; it was useless. There were no NSAIDS [NonSelective (non steroidal) AntiInflammatory Drugs in the Navy in those days other than aspirin which proved to be worse than just ineffective; it caused gastrointestinal bleeding, something Joyce did not need. Corticosteroids had proven to be hazardous for long term use. So, I prescribed oral opoids, first acetaminophen with codeine, which helped a little and for a brief time. I upped the dose to the maximum but had to discontinue it because of severe obstipation and the fear of resultant blockage of the bowel.
Joyce’s problems multiplied. First, her son and husband were caught having sex with the base executive officer’s daughter; she was underage; and both men were adults. I was called to mediate between Joyce’s family, the girl’s family, and the Shore Patrol. My main goal was to keep the information from getting to Joyce, which would be a final blow to her already fragile psyche, by then. We achieved a compromise of sorts. The XO and his wife agreed not to press charges; the police agreed to keep everyone’s names out of the newspapers; and the two men of Joyce’s family agreed to accept transfers to far away places with strange sounding names.
Back to Joyce’s manifold issues, she was requiring progressively larger doses of stronger oral opiods, then IM morphine, and finally, I had to order IV morphine. She was rapidly losing weight, becoming weaker, less able to hold down food, and short of breath. The pain was becoming excruciating despite IV doses that kept her drowsy most of the time. The only thing she did not have was evidence of brain metastases, no small blessing. I put her on hospice care at home which meant she could get unlimited morphine IV for her pain without her or me having to jump through hoops. I was not in the mood.
Neither the Navy nor private nursing services had nurses to spare. I became her hospice nurse by default. Finally, in her last few days, she could not eat, could only take sips of water to keep her tongue from drying out and turning black, and was requiring what were generally considered maximum doses of morphine. I began sitting at her bedside at night; so, I could give her the morphine and be the one brave enough to increase the dose as needed. I began holding my breath every time I pushed in another dose, and they were becoming more and more frequently necessary. Both she and I reckoned that we had come to the last day. I spent all of it with her.
We talked about the Navy, about surgery—she loved stories of my surgical adventures—about her husband and son, about books I had been bringing her to read, and about a little game I improvised. We took turns telling pleasant meaningless little stories about our childhoods. When I ran out of actual experiences, I made up fictional ones. Before late evening, she was too exhausted, in too much pain, and too confused to keep on.
Joyce actually knew very little about me personally, and she surprised me greatly at around 8 p.m. when she asked me to give her a blessing. I knew nothing about her church or religious beliefs. Why she made that request was a mystery, probably because at that time of extremis, I was everything she had left. I did as she requested, and she was calmed. We read the 23rd Psalm together, and she soon went to sleep. I pushed my chair next to her bedside and held her hand. She was desperately tense, struggling to maintain her dignity in the face of overwhelming pain. I gave her morphine more frequently with my personal medical endpoint being her stopping having signs of having pain. About midnight, she went sound asleep and seemed relaxed except for her uncomfortably strong grip on my hand.
At about two a.m., her grip relaxed; her jaw unclenched; and she went limp. Her eyes opened halfway. It was obvious. I did a thorough examination and pronounced her dead at 0215. Then I cried. A woman I loved, for whom I had given every sinew of care, and who loved and depended on me, was dead. I have seldom ever felt like such a failure. She and I had fought a war with a monster, and the monster won.
