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  • Writer's pictureValerie Brooke, MD

Death and Dying

I was not aware during my medical training how fearful patients and medical professionals are about the one thing that we all will experience in our lives: death. The few patients I either pronounced dead or watched die were in the hospital, usually in the intensive care unit, losing the battle against a disease such as cancer, end stage liver disease, or heart disease. It’s not surprising to me that between 13-25% of all Medicare costs occur in the last twelve months of a patient’s life. So much time, resources, and emotional energy is spent trying to outrun death.

Now that I am working as a rehabilitation physician, I am astonished how little death is talked about, not only between patients and their loved ones, but also between patients and their physicians. I have had many patients with end stage cancer admitted for physical rehabilitation, with cancer in their brains, lungs, breasts, esophagus, colons, and bones. Many are still listed in the computer system as full code, which means they would want to be resuscitated if their heart stopped beating or they stopped breathing. No one has spoken to them honestly about their broken ribs that would occur after chest compressions and their likely inability to come off of a ventilator due to their advanced cancer. They are still in the denial or fighting frame of mind rather than the acceptance mode, often but not always because the cancer diagnosis is fairly new and they along with their families are not ready to face the inevitability of death.

I don’t think there’s anything inappropriate about choosing to fight cancer with all medical options available, including chemotherapy, surgery and radiation, if that is the choice a patient makes, while understanding the pros and cons, how much more time the treatment may add to their life and what the quality of their life would be like during that treatment. What I do think is inappropriate is to not talk about the elephant in the room, the death waiting in the corner. If a patient has stage four or advanced cancer, with metastasis to other parts of the body, he or she is going to die, sooner rather than later, whether weeks, months, or years ahead. But many have not heard this from their physician, or if they have, they have blocked it out with shields of fear and denial. They are shocked when I ask them about their code status or ask about resuscitation. It’s as if they believe the treatment they underwent for their cancer will cure them, rather than be palliative or lesson their discomfort in the absence of a cure.

It is such a disservice to the patient and their families to not be truthful. Not that we always know exactly how long someone has to live, but we know as medical professionals that death is around the corner. I once admitted a patient that had metastatic lung cancer to her brain, bones and liver. When I walked into the room to see her for the first time, it was so obvious to me that she was dying. She was wasted away with little muscle mass left, short of breath while on oxygen supplementation, and in so much pain from the cancer that had spread to her bones. My heart broke as I kneeled down next to her in the bed and asked her what she wanted. “To stop the pain,” she replied. I asked her if she wanted to go home on hospice, a word she had not heard before. She had just had palliative radiation to her brain, and she did not understand what that meant, she did not understand that it was not going to cure her cancer. After help from the lovely palliative care team, she died about a week later. Her grandson asked me why palliative radiation had been offered in the first place, as it was also obvious to him that his grandmother was dying. I did not have the answer. But what I know is that choosing a treatment just because we can do something, does not mean we should offer that choice. When does is become more harmful to the patient to offer treatment, if it will only prolong the patient’s suffering? When is it more harmful to allow a patient to remain a full code, or do everything possible, when the body starts to shut down?

I know there are so many factors that contribute to our society’s inability to discuss death. It’s seen as a failure in medicine rather than as an inevitable part of the cycle of being human. Death is natural and can be a beautiful transition rather than a fearful one, if we as a culture decide to talk about it. And, if we start the discussion sooner rather than later, a patient can have more than a week to come to terms with their impending death, so they can talk to their children and friends, and have time to say goodbye.

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