Friday, February 23, 2007

Dying on schedule

This weekend I watched The Barbarian Invasions, a Quebecois film about the last days of a man dying from cancer. The man’s son, an investment banker in England, flies home to help take care of his father, going to extraordinary lengths to ensure that he dies as happily and comfortably as possible. Thanks to the son’s efforts, the father’s final days of life are a veritable love fest filled with lavish foods, intravenous heroin for optimal pain control, extended visits from family and friends, video messages from his daughter who is out at sea, and time spent at a peaceful and breathtakingly beautiful lakeside cabin. Then, on a final starlit evening, after all have said their farewells and as if it were the most natural conclusion to a life well lived, the father’s aid helps him end his life with a lethal dose of heroin. The son holds his father’s hand and everybody else looks on approvingly. This, the film boldly seems to state, is dying at its best, on one’s own terms and on one’s own schedule.

Is it such a ridiculous proposition? All of life’s other important events—weddings, graduations, birthdays, celebrations of any kind, really, occur on a schedule. They are better that way: the food stays warm, the band gets booked, the necessary preparations are made, and most importantly, the guests show up. Even in medicine, which deals with problems unconfinable to working hours, we are able to arrange most things on a schedule. If you want to see your doctor, you make an appointment, hoping you’ll still be sick when you finally get to see him. If you need surgery, the surgeon will give you a date and time. An MRI of the head? Book it in advance. Even for our hospitalized patients, it’s rare that a service is provided without the patient first being put on a schedule of some sort. Emergency procedures and surgeries are risky and stressful for everybody, so scheduling them is almost always better, even if the scheduling is for later in the same day. Waiting until a problem becomes emergent is simply bad medical practice.

Emergencies do still happen, of course. In medical school, on explicit instructions from the attending surgeon and in a futile attempt to speed up a surgery, I once hijacked a patient from the ER, commandeering his stretcher and carting him up to the OR myself. Although I got high fives from the surgical residents for this, the nurses and OR staff were less than pleased. I was thoroughly chastised, in fact, and told how much it actually slows things down when patients are carted around without the proper paperwork, before the nurses have had a chance to give each other report. I apologized, but the rush from flying that patient around the hospital at full speed lingered.

Yes, unpredictability and spontaneity make life fun and exciting, but is death really the time when we want them? For healthy people clairvoyance is more likely to be a curse than a blessing; knowing the date and time of one’s death well in advance would certainly precipitate bizarre and unwanted psychological side effects, such as wanton recklessness, or mad last minute attempts to cheat death. For people who are actively dying, though, it seems that the more transparent the process, the easier. Families of dying patients are certainly always hungry for more information about what is happening with their loved ones. Physicians, though, are often less than forthcoming, uncomfortable with predictions and quick to explain that they don’t hold crystal balls. Would we want them to? Surely if dying meant catching an airplane to the other side, we would want to know what time it left so that we could show up to the gate on time with our bags packed. The Vikings buried themselves in their ships because they seem to have considered boating to be one of the best ways to travel to the afterlife; maybe it’s just the Viking in me that thinks knowing a departure time might be nice. Granted, some hopes might be shattered by definitive knowledge of impending death, but after all, those hopes would have been false anyway. For most people, I suspect that knowledge would provide peace and comfort.

At least some warning certainly would be nice. It is the sudden, unexpected deaths that are hardest for families to absorb. People who rapidly go from healthy to deathly ill leave a path of destruction in their wake, giving friends and family no time to adjust to the change in condition or to let them go. The Grim Reaper is perhaps one of the most feared characters in the human imagination, but at least if you see him lurking in the background, you have time to say some final good-byes. A close friend of mine whose mother recently passed away told of how her father called her home from work early on the day of her mother’s death. Her mother was just holding on when she arrived home and seemed to have waited for her to arrive before letting go. Having a chance to say that final good-bye meant a lot to my friend. They were fortunate, but death can be quite difficult to predict, and her mother might have passed suddenly, without notice. There might easily have been no warning.

Often there is none; death comes swiftly and abruptly. A young man, a father, can be perfectly healthy playing basketball one moment, and lay dead on the floor the next. Alternatively, a dying person, having made his final peace, might lie around for days or even weeks in waiting. The farewells are finished, the permission from family members to pass has been granted, and the personal demons have been worked out, but upon closing the eyes, nothing happens. The person experiences terminal insomnia, the most insufferable kind. Who is to begrudge that person a little heroin as a sleep aid, just to help keep his flight to the other side, or to shorten the layover? Who has the right to tell him that he must toss and turn on his death bed?

Most people, I suspect, would answer that God does. But, even conceding God for a moment, is it really He who determines when people live and die? As physicians most of us consider our patients to be in our hands while they are still alive, not God’s; that is, their diseases are ours to cure, or to fail to cure. When we extend lives we certainly don’t feel guilty about keeping God waiting. Why then, can we not hasten death, or put it on a schedule? Great care would have to be taken that it was truly the dying person’s schedule and nobody else’s, but why must we obsess so about securing those final days or hours of life? In the film, at an earlier point when the father admits fear of dying, his caregiver questions him about it and concludes, “It’s not the present you cling to. It’s your past life. That life is already dead.” She makes a valid point—unless you have urgent unfinished business, the process of dying is not about living. Hours spent dying are like hours spent on an airplane: they are to be passed, not necessarily enjoyed.

Phrased in the more familiar language, I suppose I am asking, do we have a right to die? Conversely, do dying people have an obligation to endure the entire natural course of their death, as a final rite of passage? For many people, their religious convictions state that they do. For those with more flexible belief systems, though, hastening death may be a reasonable option. I don’t think I would ever schedule my own death, but for those who prefer an earlier flight to the other side, well, I wish them a peaceful journey. And, in case their plane falters, I’ll be right behind in my Viking longship.