Die with dignity or anguish: The choice is yours
I am conflicted about the health care bills making the rounds in Congress today. The mandate for reform is writ large on our national landscape and few issues are more pressing than universal access from my vantage as a practicing physician. But I have written before of my concerns regarding the public option and my distrust that our government could effectively manage and implement health care for its citizens. When I witnessed the surreal and spurious protests from the Tea Party activists and other opponents of health care reform that galvanized around so-called "death panels," however, in many ways, I saw a drift into irrationality.
Here are the facts: Care for the 1 in 20 Medicare patients that die each year gobbles up fully one-third of the entire Medicare annual budget. One third of expenses in the last year of life are spent in the final month with aggressive treatments in the final month accounting for 80 percent of those costs. Meanwhile, a recent study in the Annals of Internal Medicine demonstrated that if only half of the 500,000 Americans that die of cancer each year were to have an end-of-life discussion, $77 million would be saved. Even more, palliative care improved the quality of life at the end, while aggressive care did not prolong survival at all.
The demagoguery went beyond the pale in the far-right's contention that the health care bill's allowance for patient-doctor visits to discuss end-of-life care would "ration Grandma's care" and let death panels decide the value of her life. We always knew that no such abuse was written into the bill. But the rabid endorsement of this myth from political opponents of the President, targeted at the voting demographic of senior citizens, was emblematic of a much deeper wound on our nation's psyche: our inability to accept the inevitability of death.
The Hindu Vedas say, "Free of desires, wise, immortal, self-existent, full of bliss, lacking in nothing, is the one who knows the wise, unaging, atman (soul); that person fears not death."
To a Hindu, then, refusing to accept the inevitability of our own, or loved one's death, "fighting till the end," refusing to give up in the face of the inevitable--these are all manifestations of our own ignorance. There is no death; the soul simply continues its transmigration through reincarnation until the ultimate destination of moksha, or salvation, is reached.
We have built a narrative where not giving up, holding up hope is heroic, and capitulating to death is cowardly. And indeed, we must face disease courageously, trust our physicians, maintain a positive attitude and pray. But there is a time for battle, an age for battle, time for prayer and then an acceptance when the outcome is certain.
I do not pretend to have experienced the death of a child, a spouse, for example, where all of the ideal calculations we shape in our mind become irrelevant. But as a pediatric surgeon, I know that the equation of death comes in degrees also. A child leaving a family prematurely affects a societal calculation differently, perhaps, then the timely passing of an octogenerian leaving the clutches of an aging, aching physical body.
And I can recall the angst ridden, but gentle countenance of the eighty-two year old woman in the intensive care unit when I was a resident. I was asked to put in a central venous catheter as all of the veins in her arms and legs had "blown"--there was no way to get more medicine into this woman suffering the end stages of the ravages of pancreatic cancer other than placing a long needle deep below her collarbone into deep vein. Long-term survival was impossible--virtually impossible. And this "virtual" possibility disabled her family from making the call that she anguished for...allow her the dignity of a gentle death. The most painful of needles, the incessant beeps of the ICU monitors, no control over bowel or bladder: these were to be her fading memories as we all--straitjacketed by the family--conspired to force air, fuel and fluids into a body that could take no more.
An advanced directive would have saved this woman untold misery, and its need is indisputable. It is a public health imperative. Yet, as with many public health directives--exercising, stopping smoking, wearing seatbelts, avoiding drugs and alcohol--our public must be educated. But for all of the resources devoted to those issues, we continue to deny Americans the opportunity to discuss with a physician and others how they can write their own advanced directive.
If we don't leave a will for our children, our assets go to probate; don't leave a living will, and you may not control what happens to your best asset--you!
November 5, 2009; 5:16 PM ET
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