Early on in my career I called an Indian internist in the middle of the night to admit a patient to him.
The patient was an 88-year-old female with advanced dementia, a terminal brain disease. She had aspiration pneumonia, which is often the final common pathway of this illness. She was in respiratory failure, in septic shock and was a “full code.”
I can still recall our 4 a.m. conversation:
“Hi, Dr. M this is Monica Murphy in the ER. I have an 88-year-old female with advanced dementia who has pneumonia and is septic. I intubated her; she’s got a central line with antibiotics and pressors hanging, so we need to admit her to the intensive care unit.”
There was a long pause … entirely too long.
I said, “Hello, are you still there?”
He answered with a question, “Are you new?”
I felt a bit bumfuzzled by this response, “Yes.”
After a briefer pause, he asked, “Are you American?”
Then, he let me have it, “What’s wrong with you Americans? Why do you not know when to let your people die?”
It was my turn to pause. I was in a state of shock. What? I had no idea how to answer this question! I was calling to admit a patient not have a philosophical debate. However, I felt a bit shaken because I thought it was possibly a very important question. I was even more shaken by the fact that I did not have inkling as to the answer. (Young doctors fresh out of training like to have all the answers. They fantasize that they have been trained to approach every conceivable permutation of patient care. Yet, the answer to this question eluded me.)
Finally, after my own long pause I responded, “I do not know, but I will certainly think about that …”
After I hung up the phone with this Indian doctor, who is now a friend of mine, I wrote down the question very neatly on a scrap piece of paper.
“Why do we Americans not know when to let our people die?”
I stared at it for a while before putting it into the pocket of my white coat. The note ultimately got washed up in the laundry, but it remained clearly etched in my mind.
It took me about four years before I could answer the question in any logical manner.
Very recently, I had the honor of speaking to a distinguished group of Indian physicians. I recounted the story to an amused audience and then gave my routine lecture about preparing for peace at the end of life. Unlike most American doctors, they were neither startled nor shocked when I said that there is a time at the end of a long life or terminal illness when it is okay to die. Instead, it seemed like old news to them. Some even yawned.
In speaking to many different cultural groups on this topic, I have found that by and large Indians and Indian physicians have the healthiest perspectives on death, dying and the end-of-life.
And why is that?
Why do Indian physicians know when to let their people die?
Now, I do not purport to know all of the reasons, but I am willing to take a few wild guesses:
1. Indian physicians (who make up about 10 percent of the physician population in the U.S.) tend to be generationally closer to seeing natural death as culturally acceptable compared to most American physicians who are probably 2 to 3 generations removed from the same.
What do I mean? Dr. M who quizzed me on the phone that night, also told me the story of his own father who died at home, in his own house, in his own village, in India. Natural death and dying processes were recognized and respected. In contrast, both of my grandmothers died in hospitals, and I didn’t personally know any relatives older than them who died at home in the same natural fashion as Dr. M’s father. He allowed his father to die naturally and advocates the same for his dying patients. He appears to know when to let his family die, and when to let his patients die.
2. Hindu philosophy supports preparation for death. Beginning when a man becomes a grandfather onward in time, the Hindu man is guided to begin the shedding of attachments to the elements of life, so that as death approaches, ideally no attachments remain to the earthly sphere of things. Very interesting.
In contrast, Western culture seems to practice attachment. We want bridges named after us, and we don’t want to let our dying elders go. We collect things as we age rather than shed things. And, as a general rule, American doctors do not know when to let their people die.
There are many other reasons, I am sure, why Indian physicians manage death and dying better than American physicians, as a whole. But, instead of me taking wild guesses, why don’t we hear from some Indians and Indian physicians themselves? We would like to hear firsthand what you can teach us about the end of life.
Monica Williams-Murphy is an emergency physician and author of It’s OK to Die.