Humainologie creative dialogue TONIGHT October 18 starting at 7 PM with synopsis of a new book Death

“Death never takes a wise [person] by surprise; [they are] always ready to go” – Jean de la Fontaine  https://en.wikipedia.org/wiki/Jean_de_La_Fontaine   

Our creative dialogue on mortality and related challenges is tonight starting at 7:00 PM.  If it goes as planned, we'll bring the dialogue to conclusion by 8:45 PM.  

My synopsis of a recent book, Death Interrupted: How Modern Medicine Is Complicating the Way We Die, is appended.  It may be very helpful to you in preparing for your own demise.  The author is a remarkable young man, with experience as a paramedic, a physician, and a journalist. 

Here is the Zoom link for tonight:

Topic: Dialogue session on mortality and related challengesTime: Oct 18, 2022 07:00 PM Mountain Time (US and Canada)Join Zoom Meetinghttps://us02web.zoom.us/j/89079130932?pwd=Z2xjUmFBbTRZNDNBT04vVTNmdUVCQT09Meeting ID: 890 7913 0932

Passcode: 12345

If you are immortal, you do not need to attend. If you are facing an early death, your contributions will be especially valuable.  We can better prepare for our own endgame if we know how others have done it brilliantly. Arthur Book: (Blair Bigham, MD, 2022)

Death Interrupted: How Modern Medicine Is Complicating the Way We Die             

“This book is about a place worse than death,” writes the author in the Introduction.  “A place where doctors despair at the hope families cling to as we poke and prod the patient, pandering to our own egos, afraid to acknowledge that we have failed in our role as life-savers.  It is about the space between alive and dead, a space I hope never to occupy personally but one I am guilty of filling, over and over again, with others I’m tasked to care for.”            

In Chapter 1, “Policy 4.4,” Bigham describes his experience as a paramedic.  Policy 4.4 is a list of criteria established by the Ministry of Health in Ontario, that qualify someone as “obviously dead,” and paramedics use them – rigor mortis, signs of decay and so on – to determine when to give up efforts to save a life.  Later, years after medical school at McMaster, as a practicing physician, “I never came across a patient who met the criteria of Policy 4.4.”  For paramedics, the decision about life or death is straightforward; for doctors, not at all.   Hundreds he has cared for during the coronavirus pandemic have required life support.  Families are often conflicted about when to let go; it’s not taught in medical school or discussed much by health professionals; and that led him to write this book. 

In Chapter 2, “A Brief History of Death,” we learn that in Victorian times, there was a fear of being buried alive.  Two hundred years ago, people died at home.  Death pervaded life.   Infant and child mortality, lack of therapy for infectious diseases, and other factors put life expectancy in the 1800s at about thirty years.  By 2000, life expectancy was nearly seventy.  The change resulted from such things as handwashing to virtually eliminate “childbed fever” that had killed one in ten women shortly after giving birth (1840s Vienna) and the removal of the handle from a contaminated communal water pump to cut the numbers of cholera deaths (1850s London); and, in the 1950s and 1960s, advances in resuscitation technology.  “People were living longer, we were becoming less comfortable with death, and we were more capable of prolonging life artificially. It was the perfect recipe for creating a world where people, and their doctors, would forget how to die.” 

In Chapter 3, “A Modern Day Disruption,” the author further explores advances in medicine. In 1952 in Copenhagen, an outbreak of polio prompted a physician to try ventilating patients and thereby reduced the deaths from 80 to 40 percent of patients.  Ventilation was done by hand – until Forrest Bird, a Second World War pilot from Massachusetts fascinated with high-altitude flights, went to medical school and (by 1957) created several prototype ventilators.  Cardiopulmonary resuscitation - the familiar method of pressing on the chest to keep the heart pumping inside – also came into being in the second half of the 20th century. 

In Chapter 4, “Welcome to the Grey Zone,” Bigham writes: “The death dilemma is, to some extent, a result of our often-indiscriminate application of technology to prevent in the short-term a death that will ultimately come anyway, but it also stems from our failure to address the ways our dependence on technology has dehumanized the practice of medicine and the process of dying.  In this chapter, I’ll explore how patients have ended up tethered to machines, unable to die, as their doctors stare at computer screens far away from their bedsides.” 

Chapter 5, “Declaring Death: Who Decides When the End Has Arrived?”  mentions advantages an experienced physician has in determining (from diverse signs) that it’s time to let the patient go.  Doctors are fallible, and even if they were “right” (whatever that means) 99% of the time, there would be many cases in which a family member and a doctor disagree.  Also receiving attention in Chapter 5 are cases taken to court; the influence of religious beliefs about when life comes to an end; and disagreements within the medical community itself about basic issues and individual cases.  

Chapter 6, “The Root of the Death Dilemma: An Equation,” emphasizes the trend toward unrealistic expectations for medicine’s ability to postpone death.  The desire to postpone death has indeed led to sustained efforts to do that, and the resulting benefits are undeniable. However, even if death is postponed, many cases are condemned to a quality of life which in Blair Bigham’s view is worse than death.  He refers to an unfortunate tendency that he calls “resuscitation glorification,” and suggests a “Death Dilemma Equation,” specifically Technology x (Resuscitation Glorification + Death Denialism) = False Hope.   

The foregoing chapters are organized in two parts, Part I, When Is Dead…Dead (Chapters 1-3) and Part II, “What Does It Mean to Die?” (Chapters 4-6).  Chapters 7-10 are in Part III, Accepting Death as Part of Life. 

Chapter 7, “A Good Death: How to Prepare for the End,” emphasizes the importance of making your own wishes known in writing about how far you want caregivers to go with efforts to keep you alive.   It may be better to give the power of attorney for those decisions to someone who is not a family member.  For families, conversations about when to let their relative go can be difficult, even proactive conversations in which the relative participates.  To help with that, Bigham refers to websites like the Conversation Project https://theconversationproject.org/    Euthanasia, legalized in the Netherlands in 2000, and later in Canada and in a few states in the U.S., is not easy to access.  There is also a Catch-22 involved:  You have to be mentally competent to give the green light to go ahead with it, and that mental competence can be lost if you wait too long, enjoying things hour by hour in your final days.  

In Chapter 8, “Life After Death: The Legacy of Organ Donation,” we’re reminded that recipients and donors alike can benefit from organ donation.  If I can donate my organs so that others may live, that can bring comfort to me in my final days.  But how viable will my organs be?  The most viable organs are those from patients who have clearly met the criteria for brain death; they can be removed from the decedent and transplanted to the recipient quickly.  The dead donor rule, however, requires that the potential donor be unequivocally dead before an organ is removed; and sometimes that means that the heart has to have stopped beating for five minutes before the donor can be declared dead.  The delay reduces organ viability.  For this reason, the dead donor rule has been revisited. Bigham is optimistic that better practices and outcomes will evolve. 

Chapter 9, “Do We Really Have to Die?” describes Bigham’s experience as a paramedic seeing “frequent fliers” – people repeatedly flown to the emergency room because of things related to their dysfunctional social situation – which led him to the realization that society itself needed to change in order to improve outcomes.  And that led him to take a break from his medical residency to attend journalism school to acquire tools for societal change. “On the first day of journalism school, our professor, Rob Steiner, told us to ignore our expertise and ‘flip our assumptions upside down.’”  Having confirmed the value of this strategy with surprising things he learned in reporting about the opioid crisis, Bigham decided to apply it to the assumption that we all have to die.  Despite some surprising research in that direction, the bottom line of this chapter is that yes, we all have to die. 

In Chapter 10, “Mors Vincit Omnia - Death Conquers All,“ the author describes his interactions with another physician, Randall Curtis, who had been one of the editors of the landmark 2001 book Managing Death in the ICU:: The Transition from Cure to Comfort.  Dr. Curtis had recently been diagnosed with bulbar ALS.  Bigham learned from Dr. Curtis and rewrote the final chapter of his book.  Bigham describes giving enormous relief to the wife of a man in a terminal condition: “I told her, ‘You don’t have to make that decision [to keep life support going, which she felt her husband would not want].  Your job is to tell me what you think your husband would want.  My job is to make the decision that your husband would want me to make.’ …she was incredibly grateful that I was willing to bear the responsibility of that decision.”  

In his “Conclusion: What Should You Do Now That You’ve Read This Book?” he suggests four steps.  “Step One: Think about death.”   “Step Two: Talk about death.” Talk with your friends about it, then talk to your family, “have the tough conversations now, when the pressure is off, and everyone is calm and rational.”  “Step Three: Write about death.  Get your wishes down on paper, with legal advice.  Make sure the person you designate to carry out your wishes agrees to do so.”  “Step Four:  Live your life.” Find balance between creating joy in your life NOW and preparing for what lies ahead. 

My synopses are never a substitute for reading the book itself, and I highly recommend reading this one.