A Good Death

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.