"It's going to kill you, if you don't quit [smoking]." The more vocally poignant physicians in the ED will often give patient's "cessation" counseling, addressing vices from smoking, to sybaritic diets, inactivity, and any other habit that can lead to disease (more often than not, has already lead to disease, which is why they're in the ED). Diabetics are "encouraged" to keep their serum glucose under control. The obese are "encouraged" to eat healthier and exercise. Hypertensives are "encouraged" to take their medications faithfully. However, in the end, the cessation and encouragement counseling that physicians provide is essentially a white lie. These patients will die, despite all the intervention in the world.
While completely anecdotal, most patients do not heed the physicians advice. Chain smokers who suffer from COPD will be back in the ED in a matter of hours to days. Diabetics with poor glucose control will return to the ED frequently for hyperglycemia or hypoglycemic events. Common things being common, "frequent flyers" in the ED, while often annoyances to many health care professionals, have legitimate disease pathologies. The apathy or naivety of these patients often furthers the progression of disease. Again, anecdotal, but not many patients will heed the advice of the physician and drastically change their lifestyle in a meaningful way to combat the progression of the disease. Diabetics who do not regularly check their serum glucose or eat a healthy diet are not likely to be convinced by a 5 minute visit with an EM physician. Nor is the smoker who smokes one to two PPD (packs per day) likely to be convinced to cease smoking altogether. The ironic reality, is that no matter what the patient does, they are going to die. So will the physician giving the advice, the nurse executing the physician's orders, the respiratory therapy technician administering the breathing treatments.
Everyone dies, and I think that we as a culture hide this, and delude ourselves in to thinking that we can defeat death. There is no cure. There is no work-around. There is no secret that the affluent greedily guard, affording them longer life or immortality. I love the show Scrubs* for more than one reason, but mostly because of the character Dr. Cox. In one episode he chides JD (the main resident character) and reminds him that medicine's fixes are temporary. The premise of the episode is a patient who smokes about one PPD who comes to the hospital for shortness of breath and is worked up; the final diagnosis is pneumonia. The resident attempts to dissuade the patient from smoking by discussing the need for tracheostomy in some smokers with advance disease, as well as the increased risk of lung cancer. The patient gives the impression that he will stop smoking, but is later discovered in the stairwell smoking a cigarette. Dr. Cox's quote is below.
Dr. Cox: It turns out we can't save people from themselves, newbie. We just treat 'em. We're gonna treat that kid with a respiratory problem, and when he comes back with cancer, go ahead and treat that too.
A supplement to this quote is that of one of the physicians, for whom I work: "We don't save anyone, all we do is delay the inevitable my friend."
I unfortunately turned 25 this year, and although I would say that I have had a curiosity and fear of death since I was younger**, the reality of the "countdown" towards my cessation of biological existence seems to be approaching more rapidly than I would wish. The white lie of medicine and the delusion of our society is difficult to see through, but it is a fact that I will die someday soon. Whether it be in a traumatic event such as a motor vehicle collision, gunshot wound, or that my end comes about in a more disease oriented pathology such as pneumonia which I will become increasingly susceptible to as I age, or my mental status declining due to dementia, the cold reality is that it is going to happen. I cannot change or prevent it. While I can heed the physician's advice, which may or may not elongate my lifespan, my median life expectancy as of this moment is 75.65 years of age. In some way, limited at times, I see the reality of death at work. A recent patient in the ED, not more than a few years older than me, died from a MVC. I was not involved in their care, but the thought that that could be me, or my loved ones is very upsetting, yet surreal.
To further elaborate on my previous point that death is hidden, an increasing number of deaths occur in the hospital. At the particular hospital in which I work, during a code in the ED, the chaplains make a concerted effort to distract the family and move them to the family room. While I agree with this to a point, as there are no hysterical family members to interfere with the "care" of the patient, most of the coding that happens in the ED is futile. I do not want to die while being surrounded by complete strangers, who are placing tubes in my respiratory tract, and breaking my ribs. I would rather go out with my family at my bedside, and my death not hidden from them.
Yet, despite the fact that we all die, our society still clings to delusion death is something that happens to the unfortunate, the weak, the old, the impoverished: everyone except me. Even our speech subjugates itself to this delusion. Even those who are about to die constantly fight the reality, and to the point of the absurd. As I write this, even I think I am special, and I would likely do the same thing in their shoes: fight the disease, no matter the odds, because I might be that miracle survivor. Perhaps it's human nature, the aspiration to be unique, and we think we are the one to conquer death. I do believe that society should wake up, and death should not be hidden. Perhaps those who still subscribe (the majority) to the delusion would take a second thought prior to some fateful decision, knowing that it could bring about their untimely end, and the cessation of brain function and complete death.
I do not have a good answer for coping with death, especially at my relatively young age (and consequently, lack of wisdom/life experience). I recently read How We Die by Sherwin Nuland, MD. The book is excellent, and the author's lucubrate vocabulary is reason enough to look in to it.
Summary? We all die. Make a living will, and let your family know what you want.
*Despite the fact that the chest radiograph in the show's introduction is flipped on the horizontal axis.
** For some reason, for as long as I can remember I have had the morbid "fantasy" (read: imagined scenario) of waking up tomorrow and being on my death bed at old age. From this scenario I constantly remind myself that I will be old and frail (assuming I live that long), and on my death bed before I know it.
