Intimacy With the Inevitable

When I was accepted to medical school, I was sure that dead people would not disturb me all that much. One of my closest friends, who had been a practicing physician before leaving the medical profession to study ancient history and write novels, warned me to approach the dead carefully. He said that one of the most important rites of passage for the aspiring physician was not only to learn enough about the contours of the human body to pass the first-year course in anatomy but also to learn how to become comfortable with dead people.

I wasn’t worried. I had been educated as a scientist and was finishing up my doctoral dissertation in biology—not one to be troubled by such things. Trained to believe firmly in rationality and logic, I was trying to relegate the emotional part of my being to the basement of my mind—especially after the recent failure of a relationship with a woman I had loved.

During an orientation tour before classes started, a third-year medical student took me to visit the hospital morgue. Walking down sterile white corridors and a few flights of stairs, we came to a half-lighted hallway that gave way to a narrow passage. At the end of the passage he abruptly turned and led me into a large room in which an open steel container held a dead woman. I had expected half-torn flesh and nothing really resembling a human being, thinking that the most oppressive aspect of confronting the dead must be the smell. But the body, submerged in a solution of formaldehyde, was a recent death, and her eyes were wide open and looking upward with an expression of profound sadness. It was difficult to avoid her empty stare. I wondered who she was and why she had died, trying hard to remind myself that I was a scientist and not someone easily subject to the emotional vagaries of the unenlightened.

My guide launched into exquisite detail about how the disease process had taken her life, and I began to feel nauseated. Ignorant of the esoteric language of pathophysiology at the time, I couldn’t understand much of what he was saying, but I wasn’t listening closely, either, as I was just trying to hold my composure. I mumbled some excuse about being late and rushed outside into the intense light of a Texas noonday sun. This was fortunate for me, as my eyes were already beginning to betray me. I headed toward the privacy of my car, and once inside sobbed uncontrollably, as if my entire body were vomiting an overwhelming sadness. But who was I crying for? For her? For those I loved? For myself? I didn’t know, and I still don’t. This was just an encounter with a dead body. Only later would I become much more intimate and familiar with death—something altogether different.

I had been exposed to death as a child. I remember the day my best friend, Eric, didn’t show up for first grade. I also remember the days that followed, with frequent appearances by Sister Bruno at our classroom door to tell us that Eric was getting better and soon would return to school. Every morning I expected to see my friend. One day Sister Bruno came to our door and told us he had died during the night. I couldn’t believe it. Hadn’t she assured us that he was getting better? What could have possibly happened? Many years later I realized that she was either ignorant of his condition or a liar. My friend had acute lymphocytic leukemia, and there was no cure for it. Today childhood leukemia is curable more often than not, but in 1965 almost everyone who got it died.

My parents took me to the funeral home to say goodbye to my friend. He was lying in a box, dressed in a white gown, and he had a red glow on his face. Understanding death can be nothing short of impossible for a child. It is the same for an animal, which will stand over the body of a loved one for a long time, pawing at it, trying to get it to respond. Eric’s body was unchanged, as far as I could see, and yet I was told that he was no longer there. But he was there. I even talked to him. If my mother had not stopped me, I would have grabbed his hand and tried to wake him up.

But the dead don’t wake up. This realization may be what separates us from other animals. The cliché that logic and reason distinguish humans from the rest of the animal kingdom has never seemed valid to me, particularly because many of us behave as if we were disinvested of these particular qualities. We are, however, pretty good at recognizing death. Many of us believe in some form of life beyond our present existence, but only within the context of the next world. Unlike the ancient Egyptians, who took elaborate steps to preserve the body for the voyage to the world beyond, we bury our dead deep in the ground or burn their remains.

Sigmund Freud taught us that, second to sex, death and the response to death most define human existence. The twin pillars—the creative force of sex and the destructive force of death—are the guiding forces that shape human culture and civilization, Freud said. Synthesis and antithesis. Everything else is at best secondary and at worst meaningless.

During my medical school years, death easily eclipsed sex—if not in importance, then certainly in my own experience. Dead people filled my days, while only an occasional lover ever filled my nights. Some of this may have been the result of the low self-esteem engendered by the psychological trauma of medical school. Medical students are essentially useless in the hospital because they know little that is applicable there. Ability and training are of the utmost importance in the practical fields, and medicine—despite a proud intellectual history and tradition emanating from the liberal arts and sciences—is perhaps the most practical of all fields: only skills and knowledge—derived from theory, it is true—can save a human life. In hospitals, nurses are infinitely more important than medical students. Even the phlebotomist is a more useful member of the medical team than a medical student. Your place in the hospital is fixed and unalterable, at the very bottom of a complex and ruthless social hierarchy. Often as I entered the hospital in the early morning, while putting on the short white jacket that defined me as a student (physicians wore full-length jackets), I would say to myself, only half-joking: Once a self-respecting individual with a certain modicum of personal dignity, I am now the lowest and most contemptible form of human life, the medical student.

As such, you are regularly confronted by the dead, without being personally invested in either death or dying. You might have a courtside seat, but you are only an observer. And when a decision is to be made or an action taken to slow a disease or salvage a vital physiological function to prevent someone from dying, you fade into the background quickly. You are a theoretician with limited practical experience, and even your theory is primitive compared with that of any practicing physician.

Once you graduate, things are different. Overnight you are expected to make important medical decisions, and (despite what I believe to be a deliberate effort in our corporation-dominated culture to delegitimize the medical profession by referring to physicians as providers) you are called doctor. What you now provide is a hard-won knowledge and level of skill that will often make the difference between someone’s living and dying. This responsibility, this terrible responsibility, will define you as a physician.

During my first year of postgraduate training as a medical resident at the University of Illinois, I lived from patient to patient, problem to problem, call to call. The Washington Manual of Medical Therapeutics, a handbook that describes succinctly the management of many common medical conditions, was my trusted friend, providing answers to questions I didn’t even know could be asked. I was treading water that first year, but some incidents from the time stand out more than others.

As the intern on call for the intensive-care unit, I was asked by the emergency room physician to admit a 26-year-old woman with a subarachnoid hemorrhage. This condition is caused by a breach in the wall of a blood vessel in the brain. When the vessel breaks, blood spills into the confined space of the skull, damaging brain function, often irreversibly. The patient had been working the telephone at her customer-service job when she told a coworker she had a headache. Thirty minutes later, she slumped over her desk and lapsed into unconsciousness.

She was taken to our hospital’s emergency room and placed in a private room. Her husband put a photograph next to her bed. In the photo she was a beautiful woman sitting on a large wooden chair while holding a small boy—her son; both were dressed up and smiling happily. I turned off the lights and listened to her breathe in the darkness. Deeply, slowly, and rhythmically, her lungs took in air. Her heartbeat, strong and full, was audible even without the use of my stethoscope. I flashed my penlight into her eyes. The nerve connecting the retina to her brain could be clearly seen and its passage traced. Her arteries and veins pulsated with the flow of blood, trembling with the rhythmic contractions of her heart. Although the signs of life were present, I knew she was dead. Who she was and might have been were gone. There was nothing there but a beating heart and memories lost forever within a tangle of millions of disaggregated nerve cells. I thought about her son, waiting at home, looking for his mother. Again the overwhelming nausea struck.

As I walked out of the room, the ER physician flippantly said: “Once there was a brain, now there is nothing.” His simple statement of fact enraged me. I wanted to shout at him, to insult him, to hurt him. But he was my superior—in rank, experience, and most important in knowledge—and even if he had been my peer I wouldn’t have done it. Six months into my internship, I had already learned that reflex callousness was a defense practiced by all physicians at some point to protect themselves from the overwhelming weight and sadness of being witnesses to horrors.

On another occasion that year I assumed care of a man in his mid-40s who was having increased difficulty with his breathing. He insisted, as did his wife, that he wanted to be a “full code,” which meant he was to be resuscitated and put on a mechanical ventilator if his condition were to deteriorate further. At shift rounds, the senior resident asked me about him before leaving to cover another floor. I said the patient had been diagnosed with a sarcoma (cancer) two years earlier and was recently found to have multiple metastases to his lungs, which portends a poor prognosis. I had not seen the x-rays, having only briefly skimmed the written radiology report when I took over from the day-shift intern. The patient was one of many in my care that night, and his story passed by as quickly as did the others.

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Three hours later my code pager went off, and I raced apprehensively up four flights of stairs to the man’s room. A phalanx of family members stood outside the door. The code had already started, and the nurses were at the bedside administering chest compressions and a breathing bag. I was grateful when the senior resident came into the room shortly after I entered, quickly taking charge of the situation. The patient’s pulse had returned, and he was given a milligram of epinephrine on the orders of my senior, who asked about the man’s medical condition. I said that he was recently found to have cancer spreading to his lungs, and the resident asked me if I was sure. I said that I was. As the code continued and the nurses kept trying to resuscitate the patient, the doctor once again asked me in a voice pleading for certainty: “Are you sure?” I again told him that I was. He then called off the code, telling the nurses to stop everything that they were doing. One of the older and more experienced nurses, busy ventilating the patient, argued loudly with him. The patient had not signed the do-not-resuscitate order, she said, and wanted to be a full code. The doctor told her in a voice intolerant of dissent to stop what she was doing. Over two minutes passed before the man’s pulse finally disappeared.

I left the room, threading past the sobbing family members, and walked downstairs to the radiology department to view the x-rays. In the faint light of the primitive viewing screen I saw multiple hazy outlines in the man’s lungs, distinct shadows outlining the contours of disease and his inevitable demise. We could have done nothing for him. The decision to withdraw treatment had been right.

But what if I had been wrong?

By the time I finished the first year of postgraduate training, more and more of my rotations were spent in an old Veterans Administration hospital in Danville, Illinois. It was here that death and dying took on a truly macabre aspect. Dark and spooky and set way back from the main road on a large piece of land, the compound consisted of ancient buildings that included the main hospital, an emergency room, a psychiatric hospital, and a nursing home. The buildings were interconnected by an elaborate system of tunnels that wove across a deeply wooded landscape containing a large cemetery where the dead from previous wars were buried. An intern took care of patients in the main hospital, and the senior resident (me) managed the ER and put out whatever medical fires arose in the other buildings. Except for the often-exceptional nurses who worked that graveyard shift, everyone else in the complex was either asleep or dead: those in the ground, the dying soon to be put into that ground, and the seriously ill whom we wanted to keep above the ground—at least on our watch.

During quiet periods when I was on call at night, I would try to rest. That is when the dead from my own life would visit me, inhabiting the twilight realm that comes before deep sleep. Oftentimes a phone would wake me, and I would learn that someone in the large extended-care ward needed to be pronounced dead. When the needs of the living permitted, I would make my way through the tunnels to the “outback,” as we jokingly referred to the extended-care ward.

Sometimes on these late-night death rounds I would bring the intern with me, and we would practice our intubation skills on the corpse. If rigor mortis had already set in, getting the endotracheal tube in the airway was no simple matter because it wasn’t easy to extend the neck enough to visualize the vocal cords and the opening to the trachea. Although this practice might seem somewhat irreverent (it was never officially sanctioned), if anyone alive in those buildings were to crash that night, we would be the ones to perform intubation and put the patient on the ventilator. So we practiced life-saving skills on the dead, thanked them for their gift to us, and pronounced them.

Making such a pronouncement was a simple administrative duty. Listen for heart sounds, check for air entry, look for the response of the eyes to light, fill out the coroner’s report to document the time of death and the likely cause, and call the nearest relative, often a wife or a child. During this conversation I would express my regret over the death of the person they loved. This expression, at first an inconvenience and a duty, became much more genuine when I learned something about the person who had just died. If time permitted, I would read the medical chart and service record before calling a relative. That he had been born in Dubuque in 1922 and had two children, one of whom died of appendicitis at the age of seven. Or that he worked for U.S. Steel in Gary and eventually started his own shoe factory. Before long, feigning an interest was supplanted with concern, often heightened by admiration. Many of the men had been on the beaches of Normandy. Some had helped liberate Nazi death camps. Two had survived the Bataan Death March. One had worked on the Manhattan Project. They were born long ago, they lived, they loved, and they died.

By the time my residency ended, I had learned a great deal about death and the specific steps you can take to prevent it. But not until I treated patients with cancer did I start to learn something about dying. Most patients with other medical conditions will either get better fairly quickly, or die. Most cancer patients are relatively healthy when first diagnosed and when told they have cancer often respond that they feel fine. But something primordial is growing inside their bodies, with its own ruthlessly efficient and highly developed program for survival, and if it has spread much beyond the primary tumor, we often cannot, with our current scientific knowledge, prevent that cancer from taking their lives.

You try to be optimistic with all your patients; you have to be optimistic if you hope to win their trust, but you know that most of what you do will only postpone (and not for too long) the inevitable. Cancer often robs a person of everything before it kills them. It slowly strangles the things that make life worthwhile. As an oncologist, you learn to fear suffering much more than you fear death. By suffering I mean not only physical pain, although that is real enough. I am also talking about the emotional suffering experienced by cancer patients and their loved ones as the disease eats away at life.

I saw it with my friend Mani. We had helped each other survive the inhumanity of medical school, becoming the closest of friends. Every evening that we were free from our responsibilities in the hospital we would get together and take a long walk around the outer edge of the island of Galveston, Texas. Landmarks have changed a lot since we graduated. Gone is the path that took us past an old, rarely used airport, an unfenced tropical garden, and a pristine wetland. Indeed, the path itself is a corpse that succumbed to the associated plagues of overdevelopment and overpopulation. But not so long ago we had the outer island to ourselves—with the welcome exception of a post-rainfall riot of frogs and migratory crabs that jumped or scuttled across our pathway, seeking whatever watercourse was sure to lie nearby. The skies were particularly bright near the gardens at the edge of the bay. Artificial light receded, and we could watch the moonlight skip across the waves or we could trace the arc of the Milky Way through the night sky. We would talk about anything and everything. He taught me computer science and electrical engineering. I taught him cosmology and medieval philosophy. It was a grand bargain.

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Mani was 35 years old when he was diagnosed with metastatic lung cancer. He fought the disease silently and with great dignity for more than two years, a duration that put him in the top one percent of people with his cancer (he was always exceptional). But toward the end of his life he began to suffer less silently. On my last visit, a month before he died, Mani, who never smoked or rarely even drank a glass of wine when he was healthy, was consuming a regular dose of narcotics that could render an addict comatose. I listened to him retreat to the bathroom at night to retch and vomit (his bowel strangulated by the narcotics and his liver encased in tumors), and I remember saying a prayer for him, hoping that somewhere, somehow, some God might care about Mani.

The dead in my own life—including the loves lost still living, those that I loved who are dead, and the patients who died under my care—are many, and I suspect these losses are more emotionally damaging to me than I know. Being a physician has given me an intimacy with death and with dying that is a privilege as well as a burden. And if there is one benefit to practicing medicine today besides the enormous satisfaction that comes from helping to alleviate human suffering, it is intimacy with death. This intimacy, I believe, provides physicians with a certain immunity to the existential terror associated with death and dying, immunity not available to the uninitiated. The practice of medicine is like the grim exchange the medieval knight has with the personification of Death as they play chess in Ingmar Bergman’s The Seventh Seal. Such a chess match with death is something physicians engage in constantly during our careers, and although I am unaware of any study addressing the question of how doctors face their own deaths, I believe that the close relationship we have with death prepares us well for this unwelcome visitor when he comes for us.

I recall the story of Armand Trousseau. He was an accomplished 19th-century French physician who had observed and described a link between the spontaneous formation of blood clots and visceral cancer. When he developed a blood clot several years later, he recognized it as his death knell, and in the objective manner of the scientist chronicled its features and natural history for the benefit of others. Meanwhile, he finalized his personal affairs, correctly predicting that his death was imminent. This very deliberate and rational approach to one’s own death has always struck me as strangely remarkable—a not-insignificant triumph of the individual human spirit.

A young trauma surgeon whom I took care of while doing my fellowship training was also an astute observer of his own dying process and, in that recognition, seemed to prepare himself for death as well as anyone can. Unfailingly kind and considerate, he was respected by his colleagues and his patients, and his quiet demeanor and respectful nature belied the stereotype of the brash and arrogant trauma surgeon. After he was diagnosed with a rare form of embryonal cancer, Dr. Ronald Albuquerque placed himself under the care of my mentor during fellowship, Dr. Miklos Auber, himself as close to the ideal of a physician as one could imagine. Dr. Auber was legendary for his dedication to his patients, and it was not unusual for the residents on the night float shift to see him well past midnight, studying patients’ charts or agonizing over a lab value, hoping to find some clue somewhere that might help him save a life.

The two physicians shared a passion for music, and I suspect that this love, as well as their mutual respect, brought them together as doctor and patient. Dr. Auber’s great-great-great-grandfather, Daniel Auber, was a French composer, and I occasionally heard the product of his life’s work on the classical music station as I drove to work. I looked up his picture on the Internet and was struck by the resemblance of the two. Being only several generations apart, they were sure to harbor similar genes. But Daniel Auber was unique, as is Dr. Auber, as are all of us, with our own distinct genetic imprint and life experiences. This absolute and irreplaceable uniqueness makes the death of any one of us of such singular moment.

Two weeks before Dr. Albuquerque died, he came to the cancer clinic with his violin and played. It was a deeply felt musical display by a man who knew he was dying. Terribly frail, even emaciated, he gave a virtuoso performance for the other cancer patients hooked up to their IVs dripping assorted poisons. When the incredible sound from his violin gently embraced the people in the cancer center, for a moment, for just a moment, there was no suffering, no death; there was only beauty. Looking back on it now, I see that his musical performance was not only his way of saying goodbye to all of us. It was also, even more profoundly, his way of saying goodbye to himself.