DOCTORS AND DEATH
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The medical profession offers may interesting case studies in the death arena. The first year medical student is introduced to death through the cadaver, typically one per student or two students per cadaver. The cadavers come from body donations and they are introduced to the students anonymously. They are treated as an object of learning rather than invoking emotional responses. Sometime during the second year the student attends, and may even participate in, an autopsy. This can be quite emotional because then the case history is usually known and everything happens quite suddenly. If it involves young cadaver it can be extremely emotional.
How a doctor relates to death is determined, in part, by the speciality they enter. Death to a pediatrician is far worst than to an oncologist. A pathologist deals primarily with death, such as autopsies, tissue sampling, etc. Few pathologists are in the position to have one of their patients die. But even neurosurgeons, who may see death occurring in their patients on several occasions, do not necessarily become totally calloused. Most see death as a defeat of what they are trying to accomplish. One study indicated about 25% of doctors avoid the fatally ill. A survey of Texas doctors found that only one-half are willing to tell a patient they are dying. Surveys, in class and National surveys, indicate about 90% of people want to know the truth if they have a terminal disease. As a contradiction other surveys have found about 66% of doctors favor not telling the patient they are dying. Excuses for this kept secret include, "No one can predict that you are dying," and if you are told, "you are liable to give up hope and possibly commit suicide."
Typically medical doctors use denial to their advantage. It will be a protective facade to get them through some rough spots in their practice. Sometime in their life and/or training emotional blunting is acquired. These two techniques, denial and emotional blunting, allow a doctor to remain composed when facing grotesque situations. The fear of death and immortality thoughts are also exaggerated in the medical profession. All this is understandable when one realizes death is the antithesis of the profession. Unfortunately this sometimes leads people to believe there is a lack of compassion among doctors, and that they have an obnoxious aloofness.
Physicians have been found by survey to be more afraid of death than normal non-medical healthy people. I suspect many have subconsciously entered the profession in order to "beat death out" by preventing others from dying. This is a way of enhancing their feelings of immortality by being more powerful than the Grim Reaper. Oftentimes when a doctor is told they might have a terminal illness shear panic usually is the result. Some of the emotional blunting is stripped away. Some of the aloofness and callousness leaves. And, if the physician has the chance, they finally begin to really live.
Over the years several community doctors have visited the Death Education class to give their views on the subject. Some have attended almost all of the classes in the twenty years. My thanks to the following for their valuable contributions to the Death Education class over the 20 years:
Joseph Krivda, M.D. (deceased)
Francis C. Mayle, M.D.
Herbert M. Weinman, M.D.
Stephen R. Weinman, M.D.
Robert Taylor, M.D.
Some of the physicians been forthright with their answers to the questions asked, and some have been very evasive. Because of a strong death fear coupled with denial, some questions were ignored. Typical questions and answers are found in the following responses collected during many classes:
Q. What are your thoughts on euthanasia?
A. The majority of doctors practice it on a limited basis. I have assisted deaths of terminal, suffering patients. The patients usually indicate they do not want to continue to live. We recommend that the patient is returned to their home, if it is possible, because there are less legal hassles than in a hospital. However, if the quality of life of a patient is poor heroic treatments are often withheld with or without a DNR.
Q. Did you ever see another physician cause the death of a patient?
A. There are several cases where this has happened. One example was when a resident was attempting to insert a stomach tube and the tube punctured the stomach and intestines. The patient, a very elderly woman, later died of mammoth internal infection. There have been doctors that have ordered the wrong prescription or dosage that caused the death of the patient. There have been victims of accidents brought into the Emergency Room that were in such bad shape the physician on duty has ordered all treatment stopped.
Q. How much training do you get in medical school on the subject of death?
A. Very little, if any.
Q. Do you see any manifestations of the five stages of death?
A. Most of the time the family is not allowed in the Emergency Room so they do not show me any of the stages. The patients are either not really close to death, or they are so close there is little chance to show the stages. If a patient dies in the hospital then the job of telling the family can be difficult. After they are told there is a lot of crying usually. I really didn't know what to say to the family so I decided to go in with an older doctor with more experience to see how he handled it. The doctor sat down with the family and asked, "What do you think happened to cause this?" Following that, the news was broken about the death and that everything possible was done to try to save the life.
Q. What are your feelings on kids and suicides?
A. I seen a lot of attempts but few successes. Women usually take pills and men usually shoot themselves or jump from high places. I saw one 20 year-old that ran the car in the garage and inhaled the fumes. The features, such as the lips and fingernails, were bright pink due to the effects of the carbon monoxide.
Q. What is your reaction toward the sight of blood?
A. It's not the blood so much as the deformities that are combined with it. As a medical student, during my first autopsy and surgery I had to sit down because I got all white. I was more embarrassed than anything because I was afraid I would be labeled as a wimp.
Q. Could you describe your experience with the cadaver in medical school?
A. Three or four people share their cadaver. You encounter the cadaver during the second hour of the first day. There is little transition from the lecture to the cadaver. At first the students are queasy but after about 2 weeks they can eat lunch in there.
Q. Are the cadavers ever mistreated?
A. We've had fat fights. We were not blatantly disrespectful but the cadaver was dead and didn't know what is going on. It's all part of the process of getting use to what is happening. At first the bodies are wrapped. As you work on different areas those are unwrapped. The head stays wrapped. Some students keep the wrapping on the head but some take them off right away. Some of the bodies started to rot and they had to be replaced.
Q. Was that because they were not embalmed properly?
A. I think they tried but some just don't embalm properly.
Q. What condition are these bodies in when medical school receives them?
A. Some are cancer patients and are emaciated. Our guy was husky and died of a heart attack.
Q. Do you know who the cadaver is and has anyone ever recognized the body they autopsied?
A. I've heard of that happening.
Q. Do you ever get any good looking bodies?
A. No matter how good-looking or well-endowed they are gray.
Q. Do you get a history of the person you autopsy?
A. Yes - my person was a 2-year-old kid. They were not sure of what he died of. I had to sit down because I immediately turned white. He looked like he was alive. They cut open the head and the chest/abdomen area. They pulled the scalp over the face, and actually pulled the face away from the skull, in order to cut the skull to examine the brain.
Q. To relieve stress around death, people often use humor. Do you find that to be true when doctors are confronting a dying person?
A. The doctors joke all the time. In the Emergency Room there is a lot of joking.
Q. Have you ever gotten any very strange last requests from a dying patient?
A. Not really. People seem to die as they lived.
Q. What if the family does not want the patient to know they have a terminal disease, how would you respond?
A. I had a lady that didn't want her husband to know he had cancer. He probably knew anyway. I didn't tell him he had the disease. If he had asked I would have told him. Even daughters have told me in the most violent...one lady was going to report me to the hospital administrator if I told her father he had cancer of the lung. As a matter of fact, three days later we found another cancer in the kidney. This was a daughter and a mother that were trying to protect the father. I had a hard time dealing with that and just listened to them. I did not tell him. If he had asked me I would have told him no matter what.
Q. Do you think he knew anyway?
A. There is a whole charade these people play. The fellow was stuck in denial and these people were stuck in anger. The anger was directed at me. They were going to report me to the hospital administrator if I mention he had cancer. Once they are in this stage they may never move out of it.
Q. How do you tell someone they are going to die?
A. I don't because there is no way of knowing for sure it will happen. Also, medicine has changed so much that I don't get to do it much anymore. By the time someone gets to that point they are referred to someone else. Besides, I don't tell them they are going to die. Instead I tell them to get their affairs in order. Sometimes I get them back so they can die at home and after the other doctor has finished with them. Let's assume the patient has terminal pancreatic cancer and their whole belly is filled with tumors, what do you talk about?
Q. How would you react if the terminally ill patient was a member of your family?
A. I don't know and don't like to think about it.
Q. I don't think I have the fear of death that you have. Do you agree with that?
A. I like SCUBA diving. I've been down to 130 feet. I used to be a paratrooper.
Q. When you were in California you encountered a warehouse full of bodies of soldiers that were returned from Vietnam. Could you tell us about that experience?
A. I've got something else. Let me finish with that. (A discussion of Taoism and polarities ensued.) When I was in the army at Oakland Army Base we processed people to and back from Vietnam. This is a picture of how the people came back (showing a picture of several coffins).
Q. What relationship did you have with these bodies that were returned?
A. It's a very painful thing. It took me like 20 years to feel the pain. I would say there is that much gap. Basically, I felt nothing at the time, which is my usual method of dealing with death. If you want to know how I felt, here is a picture of German war dead packed about 10 high. Look at the expression of the soldiers that are cleaning up the battlefield. Are they happy or sad? Do you think they crack jokes?
Q. How was your education in medical school as far as preparation for death was concerned?
A. Now it is different. They now have ceremonies for the cadavers. I think my education was improper. There was no death education. It was like sex education. And that is another thing I would like to bring up: Death and sex are closely related. The five stages of death, such as denial, are the same with sex. Getting to acceptance in death has about the same percentage as those who get to intimacy in sex. Why do you think there is so much VD, AIDS, and unwanted pregnancies? People cannot think clearly. They don't see anything of the reality of the situation that they are dealing with.
Q. So you think denial is one of the big problems?
A. It's not only the denial of death but a denial of every damn thing out there.
Q. Do you fear diseases such as AIDS?
A. My first AIDS patient came in and all he had were warts. This young guy comes in with warts and I took them off. It was no big deal. Fortunately I wore gloves. He came back a month later and the warts were back. I knew there was something wrong here. This guy had about 20 warts on his chest. I didn't think of AIDS when I first took them off. These were a special kind of wart and they came off real easy. So, when he came back I asked him if he had any risk factors and he said he didn't. After I ran the AIDS test he said he was gay. There were 4 of them, and his other three buddies were all dead. I don't know why he didn't tell me that in the beginning. That is the way people are. Needless to say, I didn't remove the warts the second time. I just treated him for AIDS.
Stephen R. Weinman, M.D., one of the physicians that spoke to the class, wrote the following 2 articles and shared them with me. He kindly gave his permission to have them included here:
Death and love seem to be the two topics that universally captivate the imagination. I've learned a lot about both since medical school.
In my old high school there was a class called Death and Dying. At one point I returned as a guest speaker. I was asked to share some stories about death and how I approached it as a medical student, an intern, resident and as an attending physician. I did this for several years, until the teacher who taught it (retired).
Death is something that we have learned since the first day of medical school to ignore, avoid, and dismiss. While it exists around us in every form we go about the day with our backs to it, holding our breath when it's heavy in the air. I took the death education course in high school but there was no death class in medical school. Death was in every corner of every classroom and in every chapter of every book. But we were never taught how to handle it. Nothing exemplifies our lack of introduction to death than our first instructor, who long before had lost his ability to introduce himself.
Charlie was the cadaver I had in our anatomy class. We were herded into the gross anatomy lab exactly one hour after our first class during the first day of medical school. One hundred and fifty eager and innocent little eggheads were led down the tiled corridor of the basement floor of the school building to a large room in which resided about fifty corpses, stretched out on tables and covered with rubber sheets. Not one student fainted when we were told to undo the sheet from the torso of our subjects. I for one was a little disappointed. I had envisioned swooning of epic proportions.
The heads remained wrapped in formalin soaked sheets. All except mine, as I wanted to get a good look at the poor slob who was about to become my teacher. Charlie, not his real name, was a guy who dropped dead of a heart attack at age 60, just like my grandfather. And like my grandfather the guy looked like he hadn't exercised since high school gym class. He was quite dusky in appearance, having been dead for months, but one could still easily imagine him saying pass the bernaise sauce.
I wrapped the head back up, as my lab partners were three women who did not share my morbid curiosity. Our first assignment was to saw into the chest cavity with an electric saw. The smell of burning bone filled the large room, and it was the only time I saw anyone have a bad reaction to the situation. One of my female classmates had to leave, as she was sick. But that was the only time. Within one month we were eating our meals over the bodies while identifying different body parts.
We spent the next four months dissecting Charlie. We would remove his plastic wraps at the start of class, do our dissections and identifications and then use a turkey baster to suck the preservative juice out of the abdominal cavity and then saturate the exposed organs. At times a fat fight would break out and fat from the different cadavers was seen flying amongst the tables. Some of the groups had cadavers that were very thin and old, cancer patients usually. They had little ammunition.
Toward the end of the semester some corpses that were not as well preserved would deteriorate to the point where they had to be replaced. A new body would be wheeled in and we would all gather around the "new kid" to have a look. A few tables over from us was unveiled a cadaver with an unusually large penis. As we all gathered around and stared one of the black men in our class walked by, casually glanced at the organ and said, "I'm not impressed." I know I was.
My lab partners were two women, one of whom became my girlfriend. The other was a good friend who I constantly felt compelled to abuse. While studying the genital system she appeared to take special delight in amputating Charlie's penis. She called over to me to watch, and when I turned around she pulled up on the poor gray organ and sliced it off at the base. At the end of class I placed the organ in the pocket of her lab coat.
She didn't notice until the following day while dressing. She reached into her pocket and screamed. I believe I found myself the target of a well-aimed piece of fat later in the day.
Charlie suffered every indignity that could be imagined. Besides having his penis filleted and his testicles severed he had his head sawed in two, his heart and all organs removed and every one of his muscles dissected out from their origin to their insertion. By the semester's end it was very difficult to tell that he once was human. And yet we were compelled to continually baste him in his preservative and wrap the remains in foul smelling cloth to keep him from outright decay. But I would still donate my body to a gross anatomy class, as overall the bodies were treated with respect; despite the antics of highly stressed and easily amused young adults.
Probably the one scene that stands out in my mind above the others was the head and neck practical exam. During practical exams we would have fifty stations at which bodies with excellent dissections, either done by students or done by the instructors, were labeled and the part would have to be identified. Many of these wonderful dissections were done years before and the body would be trotted out for either the test or instructional purposes.
In the back room of the lab bodies were stored, as it was refrigerated. I was in that room only once, but I still remember bodies hanging from the ceiling, perhaps by their ears. But that may have been a memory of the movie "Coma." I'm not sure.
Well, I'm sure the thought of fifty bodies in various states of dissection lying around room is unpleasant enough for most people. But picture this. Fifty HEADS around the room, sitting on top of tables. The surrealism of the scene was worth more than my tuition. And while we went from station to station during the test, the keeper of the lab was flitting about, looking every bit like Dr. Frankenstein's assistant Igor without the hump, a spray bottle in his hand constantly misting the bodiless heads with preservative. He was quite proud of the dissected out facial nerves, nasal cavities and scalp muscles that for fifty years have tested students on their knowledge of the head anatomy.
At the end of the test the heads are wrapped in preservative-soaked cloth and stashed in the cold room until next year's class comes around.
Letting Patients Go.
Some doctors refuse to admit defeat. I consider it a privilege to allow someone to meet his or her death without my interference. That is, someone whose time has obviously come. It's not always so obvious. It was this night.
I walked into work in an ER in Oneonta, New York. I was informed immediately that the on-duty doctor (also a free lancer) was busy with a surgeon resuscitating a gunshot victim. I walked into an unusually disturbing scene.
Mr. Faceoff, a 76-year-old man with terminal cancer, had decided he couldn't stand the pain of his disease any longer and had opted to end it all. Since his doctor was prevented from helping out by law, Mr. F took matters into his own hands and put a shotgun in his mouth. Unfortunately for him, the gun was pointed at an angle when it discharged and instead of blowing his brains out it blew the left side of his head off. The only thing I believe left intact was his brain.
Mr. F's left eye, ear and cheek were gone. His mouth appeared mostly intact, although there was so little of his face on the left side that the mouth kind of hung in thin air. His sinuses were open and exposed, as was the skull surrounding his brain. Actually, there was a hole through which you could see seemingly intact brain matter. Mr. F was in very bad shape.
As a matter-of-fact, he had succeeded in killing himself. His heart had stopped and he had stopped breathing. That is, until the paramedics intubated him and the doctors started three different IV medications, considered last ditch methods, to keep him alive. They had been working on resuscitating him for about a half-hour when I arrived.
The surgeon saw me come in and continued to work, At that point the man's heart stopped again and the surgeon ordered chest compressions to begin. The ER doc gave me a quick rundown on what had happened. I just stared in disbelief. After several minutes the surgeon muttered something about having other patients to attend to. Several minutes after that the ER doc asked me if I could take over, he had to finish up some work before the end of his shift.
I looked around the room at the one nurse who was in charge of administering medications, and the other who was doing the chest compressions.
"Anyone opposed to stopping this?" The nurses shook their heads.
I pronounced the man dead several minutes later.
I believe when someone has decided to end it all, and they've really thought it out and given it all they have (not the teenage girl who swallows a bottle of Tylenol because she got in a fight with A. her boyfriend or B. her mother) their wishes should be respected. This gentleman meant it; he just had poor aim."
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