We’re all gonna die.
It’s a simple truth that an astounding number of people neglect to acknowledge or accept. Some people die sudden, unexpected deaths, but most eventually fall victim to chronic or terminal conditions like COPD, heart failure or cancer. As a palliative care physician, I often meet patients who have had conversations with their families about their end of life wishes and have completed supporting legal documents.
While I appreciate the forethought, these patients and their families are, well … boring. They typically get along, are united in medical decision making and are supportive of each other. They almost never yell at doctors, show up at the hospital intoxicated or get escorted out by security. These patients are usually comfortable and peaceful, knowing that their wishes are being honored and their families are united. They take advantage of the time they have to say their goodbyes, hug their grandchildren and savor that last piece of chocolate cake.
Now, this is all well and good, but as a palliative care doctor, this poses me absolutely no challenge. It makes my job entirely too straightforward. Like most physicians, I’m a competitive person and prefer difficult cases to keep me sharp. And extra drama makes me feel like I’ve just stepped onto the set of “Grey’s Anatomy!”
So, for the sake of my job satisfaction, I would like to offer the following suggestions to make your dying process as dramatic, confusing and uncomfortable as possible.
1. Under no circumstance should you establish a durable power of attorney. This will only serve to clarify surrogacy and simplify the decision-making process. Boring. If you are absolutely compelled to appoint a DPOA, make sure it’s the most unreliable and emotionally unstable person you know. Perhaps your co-dependent son Todd or your unreliable sister Martha.
2. Never fill out an advance directive. And for the love of Pete, don’t tell your family anything about your wishes for medical care. When you eventually lose consciousness, it will be so much more interesting to try and guess! I assure you that half of your family will think that you should go home and die comfortably and the other half will insist on hooking you up to every possible life support contraption imaginable.
This disagreement will lead to shouting and, if it’s a good day, a physical altercation! All the while, Martha will be anointing you with her essential oils, adamant that her lavender/eucalyptus potion will cure you. Now we’re having fun. I will say, if you feel badly about not sharing your wishes with your family, do me a solid and wait until $#!t is hitting the fan. There is nothing like a good “goals of care” conversation while the crash cart is being steered in by a nursing student, the intern is about to pass out in the corner, and the critical care fellow is ordering a massive transfusion protocol. This is when things get exciting! I feel a STAT palliative care consult about to jolt my pager!
3. Mention at least once in your life that you would want your doctors to “do everything” to save you. Now I recognize that this is counter to #2, but allow me to explain. If you say “do everything” or some iteration of that phrase, your family will declare repeatedly, “She’s a fighter!” and will cling to this with every shred of their being. They will interpret “do everything” as definitive, no exceptions, caveats or qualifiers.
We all know if you are dying of a terminal disease, doing everything makes no sense at all. But hey — allowing your body to die naturally and comfortably is boring. Life support machines are fun!
If cancer has overtaken your lungs, my pulmonary friends would love to put you on a ventilator. When your kidneys shut down, my buddies the nephrologists would be stoked to put a big catheter in your neck and start dialysis. When your heart is so weak that it can no longer beat normally, we’ll have the intern try to shock it back into rhythm.
Undoubtedly Todd and Martha will be standing by your unconscious body shouting: “Keep going! She’s a fighter!” Rocky Balboa has nothing on you, baby! Your dialysis machine will hum, your ventilator will alarm and your medical team will stand by waiting for your heart to stop. Then they will send the medical student to pounce on your chest, breaking your ribs with her futile attempts at CPR. Now, does it make sense to do all of these things? Absolutely not! But that’s what I call going out in a blaze of glory! And your memory will live on in infamy when that poor medical student cries to her therapist about how she tortured you in your final moments.
4. Refuse any medication to ease your suffering. The most effective medications to manage pain and air hunger are opioids. Your doctors know that these medications are completely appropriate to use for uncontrolled symptoms and that they will not kill you. Todd and Martha do not need to know this. I want them to look at me and say, “We don’t want her to suffer, but do not use morphine. Oh, and keep doing everything, because she’s a fighter!” That’s like asking me to go to Mars in a rowboat. This is the part where the camera zooms in for a close-up, Eye of the Tiger plays in the background and I say, “Challenge accepted!”
5. Please hold out for a miracle. If there is a surefire way to prolong your death, it’s insisting that your doctors continue to give you fluids, antibiotics, and artificial nutrition because you are waiting for God to heal you. Interesting how God is completely powerless without normal saline and Zosyn. Even my next-level palliative care ninja skills can’t overcome that line of reasoning. Pass the lavender oil!
So, to reiterate, if a painful, prolonged death is your jam — follow steps 1 to 5.
If you’re boring and thoughtful and want to die peacefully and comfortably, do the exact opposite.
Discuss your wishes with your family, establish a DPOA who has good coping skills and complete an advance directive. Be open to using medications for comfort if necessary. Continue to believe that God has your back, but acknowledge that the miracle you are hoping for isn’t necessarily the one He has in mind.
And should you need extra help, please don’t hesitate to ask for a palliative care referral. We’re not always so sarcastic, and we actually like you boring people.
Christi Bartlett is a palliative care physician who blogs at her self-titled site, Dr. Bartlett Pear.
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