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Author: Sumer Verma, M.D.

Introduction

The desire for immortality is as old as the story of mankind. The quest for a longer and healthier life has been inextricably linked to delaying death. While so much of the mystery that surrounds the beginning of life has gradually been revealed, what happens after death still remains a mystery. Does the body lose 7.5 grams at the moment of death? Is that the weight of the soul? Is there a soul and is there an afterlife where we are reunited with all those that went before? Literature, religion, philosophy, and medicine have speculated endlessly on these topics and still we remain ignorant.

It is accurate but pointless to suggest that we begin dying the day we are born. Physicians are intimately associated with the process of dying. For the physician, dying has many beginnings and many trajectories and to each the physician brings his or her own fantasies, fears and feelings. The purpose served in entering into this discourse is in some way to “de-mystify” death and in doing so help to create within each clinician a set of reasonable and rational responses to deal with a difficult aspect of the” sacred covenant" between doctor and patient.

Stages of Dying

In her seminal writings on death and dying, Elizabeth Kubler-Ross outlined the stages that a dying individual adjusts to the last phase of life. Denial, anger, bargaining, depression and acceptance she noted, are the stages in which we deal with dying. Another way in which dying and death can be viewed is by dividing the stages into psychological, social, biological and cellular. Dying may be sudden, compressed into a few seconds or minutes (as in traumatic death) or be drawn out over years if not decades (as in chronic debilitating disease). Dying can be premature or expected – even desired. Death can be planned as in suicide or execution. Dying can be painful or peaceful – agonizing or graceful. No matter how the process plays out, it inevitably ends in one universal process -- death.

There have been many ways to determine the point of death but recent advances in technology have stretched the limits of this definition. Death was felt to occur when a person’s heart stopped beating and bodily function could no longer be sustained. A standard technique that used to be employed to determine death was to hold a mirror to the ”dead” person's nose and mouth and if breath did not condense on the mirror, the individual was presumed dead. With the advent of EEG and the ability to delay cell death in order to “harvest“ organs for transplanting, the “flat EEG” became the standard of care with respect to determining death and turning off life support systems. In this day however, when cryogenics purports to freeze an individual for “resuscitation” at some future point, can we ascribe the status of dead to such a “person?"

The Ethical Dilemmas

The task of the physician in managing the end of life becomes extremely complex. On the one hand, there is the legal and moral requirement to not end life prematurely while on the other hand is the moral injunction to “do no harm." Is withholding or limiting care always to be viewed as “euthanasia," be it active or passive, or is there any way in which it is justified? Is it immoral or unethical to end another’s suffering? Should there be different guidelines and expectations about the provision of care that are based on age – diagnosis – potential for survival – “quality of life?" The list can go on endlessly. The risk in establishing any such guideline is that we then begin the inevitable slide down a very slippery slope, and history documents our inability to follow our own codes. Physicians have dealt with these dilemmas in many ways. The “slow code” and the aggressive use of narcotics to “ease pain” are well known though not spoken about. Personal convictions about the sanctity of life, guilt about “killing” and fear of legal consequences are some of the reasons that force the physician into these covert and somewhat clandestine set of actions.

What Are the Alternatives

Should the medical profession remove itself from this debate? Is this a matter that is better left to jurists and the clergy to resolve? Regardless of who is the final arbiter of this debate, it will ultimately come down to a decision made between a physician and a patient. We have laws and codes of conduct that have evolved over the history of mankind. The difficulty is that our technological advances have outstripped our moral codes and I do not believe that responsible clinicians can or should be excluded from this debate. We need to develop a set of guidelines that provide for the rights of providers and patients alike. To needlessly prolong suffering is against the Hippocratic code but there is an equally strong prohibition against the “taking of life.”

Dealing with the terminally ill person is akin to riding a roller coaster. Dying sends ripples through the lives of all who encounter the dying person. As physicians, we have invested so much of our being into “saving” life (at any cost) that the dying person makes us feel helpless and impotent. In addition, when we feel helpless we feel that somehow we have failed. And failure makes us feel guilty and ashamed. Suffering and dying are unique to every individual --and we can not always “fix” them. Curing and caring are different for when we cannot cure, we can still heal. From faith comes healing and from healing, comes growth.