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The proper way to die

Certain details in this entry have been omitted or changed to protect the identity of the patient.

handsOne of my patients is on the verge of dying. Not this week or even next. Maybe not even this month, but it’s close. She knows. Her daughter knows. Her physician knows.

I visited her recently. When we woke her up, she greeted us with a smile followed by generous hugs and kisses. She is a centenarian and a tough one at that. She lived through the Third Reich and then traveled to across the Atlantic Ocean just in time to protest against the Vietnam War and rally in the Civil Rights Movement. She saw the Berlin Wall topple and braved through the Cuban Missile Crisis. She celebrated when the United States elected its first black president and did a double-take when she felt it regressed eight years later. She outlived her husband. She was blessed with the many births of great-great-grandchildren.

But those days are mostly behind her. More and more, she is mostly bed bound. Her muscles are atrophying. She is ailing from painful arthritis in her knees that keep from her getting up to use the bathroom so she relies on a bed pan. Her most concerning health issue is the occasional urinary tract infection but even those are controlled with antibiotics.

She stays in a room in her daughter’s house. The room is surrounded by windows and the walls are covered by pictures of her grandchildren and old friends and family. Beside her bed lies the family’s golden retriever. A caretaker lives with the family and feeds, bathes, and cleans her.

Eating is a chore since she’s lost all of her teeth. And as a result, she has steadily lost weight and muscle tone over these past few months. Mentally, she is as aware and clearheaded as those half her age. She jokes with her visitors and teases her caretaker.

Make no mistake: There is not an ounce of grief in this household. There is no mourning. No one mopes around waiting for an impending end. The cloud of death doesn’t hang over our conversation. And she has maintained all of her dignity.

If there were such a thing as an ideal death, then this scene would be it. But this is a rarity. Only less than 1 in 3 people in this country will have the privilege of dying at home. Half of us will die in the hospital, and the remaining will die in a nursing home. But I bet if you ask anyone how they would like to die, no one will choose the hospital or a nursing home over the comfort of his own bed.

These days, the implicit rule of end-of-life care seems to dictate that we need to live until we absolutely cannot tolerate living anymore. That quaint and romantic notion of a natural death — simply succumbing to the onward current of time and age — seems far-fetched and antiquated. Death, any and all versions of it, has somehow been turned unnatural and almost unacceptable.

Yet it’s revealing that the 88 percent of physicians would choose do-not-resuscitate status for themselves, meaning they would not want any tubes to help them breathe if they stopped breathing or any chest compressions to keep their heart pumping. Maybe it’s because we know the dirty secret of modern medicine — it’s only good at keeping patients alive but terrible at letting patients live. Once a patient is past a certain age, medicine is only capable of doing the bare minimum in keeping a body alive. Even the latest and sexiest drugs on the market can only extend life by a small margin.

It’s natural to want one more day with the kids or one more weekend with close friends, to celebrate one more anniversary or to able to add one more candle to the birthday cake. Yet at some point, our bodies will give in to heart failure, cancer, strokes, or any of the infinite number of ailments going against us. And though my patient won't be able to choose what she will die from, she has chosen how she will die of it. And perhaps that is all any of us need in order to be able live out the rest of our days with hugs, kisses and a smile.

Stanford Medicine Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category

Steven Zhang is a third-year medical student at Stanford. When he’s not cramming for his next exam, you can find him on a run around campus or exploring a new hiking trail.

Photo by Gaertringen

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