Andrew Coates: An adventure to make life worth living

Apr 5, 2013

Helen Keller famously wrote that "Life is either a daring adventure or nothing."  She continued: "To keep our faces toward change and behave like free spirits in the presence of fate is strength undefeatable."

No patient goes to a hospital in search of a daring adventure. Yet in the hospital, the presence of fate is inescapable. The Grim Reaper stalks the corridors. Tragedy strikes.

One day some years ago, soon after my residency in internal medicine, I visited a hospitalized patient early in the morning. I liked him and looked forward to hearing his views. In addition to his symptoms and the plans for his care, we discussed the headlines in the New York Times.

Later that morning he died a sudden, unexpected, death. After a tearful meeting with his family I arranged for an autopsy, as they requested. Later that day I attended his autopsy, in hopes of learning from the pathologist what had killed him. Later still, the pathologist, remarkably, met with this family himself, to explain what had happened, trying to help bring some peace of mind.

In this way, perhaps the hospital can be seen as a place for a daring adventure -- for caregivers. But we need to prepare ourselves to meet the challenge.

My experiences as a hospital medicine physician led me to seek more training about the nature of suffering, about breaking bad news to patients and their loved ones, about helping with difficult decisions, resolving the goals of care and caring for dying patients. After all, a significant fraction of all deaths occur in a hospital. Of all patients with Medicare, about one quarter to one third will die in a hospital.

This week in the hospital I attended the deaths of three patients.

Each patient faced an inescapable diagnosis. Each patient refused life support measures they viewed as futile and even harmful. And each one had a triumphal death scene, with family embracing one another at the bedside, reminiscing, loving one another.

But the most compelling aspect of this work is how it reveals human courage. Our society and culture does so little to prepare us for death. And yet when death comes, the human solidarity that emerges is amazing. Family feuds melt away, people embrace religious faith -- or sometimes reject it -- they hold their convictions up to scrutiny in all kinds of ways. They confess and forgive and find laughter.

I suppose this is been true for any human crisis -- for example how volunteers responded to help strangers after the storm Sandy. Yet the hospital death scene is particularly compelling as people face the loss of their loved ones, with eyes and ears and hearts wide open.

Sometimes in medicine when a terminal diagnosis or a grave prognosis is revealed, doctors will say "there's nothing to do." I have learned that although the patient may be dying -- or even dead -- in the hospital there is always something we can do. And that sometimes very small things can mean a great deal.

One of my patients who died this week told me that she knew she was dying. "Its OK," she said. I asked what I could do for her. "I want my family," she said. For two days, as her entire extended family gathered, she rallied, at one point speaking via video call with grandchildren. Soon she lost consciousness and died.

It occurs to me that I had the great privilege to witness a woman behave like a free spirit in the presence of fate -- as Helen Keller said, a portrait of strength undefeatable. An adventure to make life worth living.

Dr. Andrew Coates practices internal medicine in upstate New York. He is President of Physicians for a National Health Program.

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