Wednesday, September 5, 2012

Mystery of the Timing of Death

As physicians, we are trained to be comfortable with things that are predictable. If your blood pressure is elevated, we bring it down. If you have an infection, we give you a medicine to eradicate the infection.  Unfortunately, not many things in medicine are quite so simple.  Of all the unpredictable processes our bodies go through, the hardest to predict seems to be the timing of our birth and the timing of our death.

This is not a column on obstetrics, so I won’t discuss birth, but the parallels to dying cannot be avoided. Mother’s agonize their last weeks of pregnancy, and family members plead with the physician for clues on when the baby will be born.  The truth is, no physician can predict when labor will begin. The same is true with dying. The final days and weeks can be agonizing as families anticipate and plead for predictions on when the event might occur.

This mysterious time for some rushes by in just a day or two and for others lingers for weeks. Do we have any control over the timing? Based on my own experience watching hundreds of patients go through this, I think that we may.  

The things that prolong dying are intuitive; that person isn’t ready to die. This refusal may be for many reasons. They may be fearful of the process itself, or what may or may not come after death. If someone is afraid to die, their spirit will fight it and what should take days, takes weeks instead.

Sometimes prolonged dying occurs because there is unfinished business that needs done. That business may be as simple as waiting for wheat to be harvested, as and elderly patient of mine did, or complex, like Mrs. O who waited to offer forgiveness to her son who was escorted in shackles from prison to her bedside before her death. Sometimes we don’t even know what unresolved business is prolonging the dying, but it’s a reason that person refuses to go.

People with a very new diagnosis or short prognosis are another group that tends to have a prolonged death.  They haven’t had time to wrap their mind around their disease, thus a part of them refuses to give into death, prolonging the process.

Finally, mothers, especially young mothers often refuse to die. Their inner drive to exist has shown me some of the most prolonged deaths. If anyone doubts that we have some control in the timing of this, I’d point you to a myriad of stories of moms with cancer, like E. who lay in a semi conscious state for over a month with nothing to eat or drink, withholding death by sheer will alone.

It is for these very reasons, that hospice refuses to interfere with the timing of death by using medications to hasten the process. It may seem contrary, but we must respect our patient’s wills, even if it is their own will that is prolonging their death. 

Whether you believe we have a choice or not in the timing of our death, the most predictable truth is that the timing of death is the ultimate unpredictable process. 

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