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A Good Death

>> Friday, October 31, 2014

Let life be as beautiful as summer flowers
And death as beautiful as autumn leaves.

~Rabindranath Tagore

Few days back, I received a mail from the European Society of Critical care. The mail was to inform us members about the family of a prominent doctor affected by Ebola virus and now in critical condition. He was a European doctor with so much of contributions in the field of medicine and had volunteered to work in Liberia on Ebola virus.

And just the week before that, Dr. Samuel Brisbane died of Ebola leaving behind his wife and kids. He was a Liberian doctor, took care of Ebola patients and died from Ebola, the horrible, nightmarish disease. Since Dr. Brisbane's death, we've learned that other doctors and nurses have also contracted Ebola and have died or are being treated in the types of rudimentary facilities we see on the news. As we live in dread of the disease, questions about how we die and what we're willing to die for, are weighing on us.

 When the whole medical field is being criticized for lack of value and dedication, we do not see the faces of those doctors who choose to work in dangerous circumstances, far away from their own homes.

Doctors and nurses have a duty of care toward their patients. We're expected, on the basis of our training and an unwritten social contract, to fulfill that duty even in very difficult circumstances - in the face of depleted resources, for example, or undesirable patients. But we also have a duty to our families, and ourselves and when our work becomes life threatening, we have to decide what benefit we will be to our patients and what cost it will exact from us. In such circumstances, we cannot be expected to uphold the same duty of care.

The ancients had a concept of a “good death” - dying for one's country, for example, or gloriously on the battlefield. For emergency medicine clinicians like us, the concept of a good death can seem too abstract, intangible. Rarely are the deaths we see good or beneficial. We see young people who die in the throes of trauma; grandparents who die at the end of a long, debilitating illness; people who kill themselves; and people who die from their excesses, whether of alcohol, food, or smoking.

The natural history of birth and death is now rewritten.

Births used to happen at home. Then modern medicine intervened and what was once a natural event,  has become institutionalized. In the process, maternal and infant mortality have dropped, which was a good thing.
Nowadays, women have a variety of choices about how they give birth. Some routinely go into labour at home, supported by midwives, and give birth in their own beds. Others start at home but head to a hospital when contractions are acute, deliver the baby, and leave a few hours later. Still others plan caesareans, or hospital birth with enough drugs not to feel any pain during labour and delivery.

Death, too, started at home. But now majority of deaths occur in hospitals, even though how we want to die is as varied as patients themselves.

Some of us will fight disease to the end with chemotherapy drugs coursing through our their veins. Others will opt for terminal palliative sedation, an induced, coma-like state to ease anxiety and ragged breathing before death. And a great many of us, especially who are aging in their own homes, want to die there, or in a hospice.

Unlike pregnant women, though, dying patients don't have a due date.

Rabindranath Tagore, the Nobel poet laureate of India wrote: “Death’s stamp gives value to the coin of life, making it possible to buy with life what is truly precious”.

Dr. Sam Brisbane's death made me think. About life, work, responsibilities and family. About those doctors who work selflessly in far away, desolate corners of the world, away from their families, in epidemics and war zones. Seldom do we remember their faces. We only know those affluent, sought after physicians who practice in the luxury of their office rooms and for whom we wait for months to get an appointment.

With apologies to his wife and family, who saw him die horribly and unjustly, and despite the deep loss we feel, I believe our friend died a good death, as did all the nurses and doctors who have sacrificed themselves caring for patients with this awful disease.


A Knock on the Door

>> Friday, August 22, 2014

Live life so completely that when death comes to you like a thief in the night, there will be nothing left for him to steal.

A recent bout with an unexpected illness has brought to mind one of the fundamentals of frugality:  preparedness.

It was all so sudden. I was at the clinic and had a bout of cough. I had this cough and cold for few days. I didn’t take it seriously first. But then I felt like sweating and then, a vague discomfort in chest.

Just the previous day, I had done my 6 kilometer regular walk followed by an hour of swimming. And I have been walking and walking for the last fifteen years, and unusually fast. I never had any problems. And I never thought it would come to me.

I was lucky.

To have thought about it, for being a doctor that I could make the diagnosis myself, to be close to the hospital, to have some wonderful doctors to take care of me and above all, to have my daughter with me at that time.

My daughter would have passed this place in transit dozens of times in the last few years. But just this time, when I went to see her at the airport, she decided to let her husband to go on with the trip and stayed back with me. We spent few days together and were supposed to take the flight home the same evening.

Do things happen for a reason? I have no clue why my daughter decided to stay back with me. And why it should happen in the morning time, when all the doctors were ready and available. When I was at the hospital, I had wondered if it had happened during my travel or at somewhere else with no access to a hospital. That is the luck I call the grace of God.

Looking back, I don’t think I was frightened. My daughter was with me all the time. And then our friend Christine who was such a blessing at that time. There was a kind of numbness about the whole episode. While I was lying on the hospital bed, many thoughts had passed my mind.

Mostly people whom I wished I could see and bid farewell before I left. Those I wanted to stay in my eyes before it closed forever. Things I had forgotten to say to some one. Apologies, which were long pending.

Here's the truth of things: if you ever had to face death, you have been brought face-to-face with the realization that tomorrow is promised to no one. This awareness can help you keep in mind what is important in life, so you don’t get lost in trivial matters and lose sight of those things that are most important to you.

It is ironic but one consequence of such sudden event is that it can make you appreciate life more than you ever would have if you had not undergone such an experience.
There is nothing like suffering and hardship to cleanse and purify us. It takes us back to the essentials of life. When everything is going well we tend to take home, job, spouse, children, health for granted. We take God for granted too.

When everything is going well we may feel we don’t need God so much. We may stop thanking him. Stop acknowledging that everything we have is God’s gift. We might get proud over our achievements or what we have accomplished. And then believe that they all happened because of our capabilities. We may succumb to the illusion of self-reliance that we no longer need God that much.

For some, death doesn’t bother knocking; it just barges in the door unexpected and unwelcome. For others, something like a cancer diagnosis can become like a knocking on the door. You get the warning, but the guest is still unwelcome. Death is the kind of guest that if you see it coming down the driveway, you lock the door and hide behind the curtains, hoping it will think you are not home. When the sound of the knock first came though, there were a few thoughts that came into my mind.

The knock made me more aware of others that had been in this same situation. Knowing that I was still at the beginning of another journey, I thought more of others who had dealt with what I had faced and how they appeared so composed and real in the light of dealing with issues that can seem quite surreal. I have to say, there is a difference between making a choice when you are healthy to when you make one after you are seriously ill.

My preparation for the inevitable does not mean I am opening the door and inviting death to come in and take a seat. I am hoping for a better life and I am looking forward to everything I was looking forward to before, only now it is with more intensity. When I hear the knocking again, I am not expecting to hide behind the curtains. But I can’t say that I won't be turning up the music either.

In the book of Revelation Jesus  says “I stand at the door and knock; if anyone hears My voice and opens the door, I will come in to him and will dine with him, and he with Me” . Sometimes, His knocking is a light tapping in our spirit. But other times, when we are inattentive, He may use a pounding fist of adversity to turn our focus to Him.


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