The Cruelest Season

By Dr. Jim Ferguson
Poet T. S. Eliot once penned “APRIL is the cruelest month…Winter kept us warm, covering Earth in forgetful snow…” Eliot’s metaphor in his poem “Wasteland” alludes to the complacency of modern man aiding the destruction of Western culture. However, I disagree with him regarding winter’s coziness. I see winter as the cruelest season, where nature selects the infirm or aged and I have observed that many don’t survive the rigors of winter.

I lost two patients last week. One was in her eighties and the other in her nineties. I was their doctor for more than three decades, and they were my friends. After long and full lives, they both were in declining health, and winter declared it was their time to go.

There is a downside to having a personal relationship with your patients. It’s safer to slumber in Eliot’s metaphoric winter torpor. However, I’m of the old school and “knowing” my patients is a privilege and, when necessary, an asset because a friend is allowed to discuss sensitive issues with them or their families – for instance care at the end of life.

In modern Western culture, people are often removed from the realities of death. Though rationally, we all know that physical life ends; however, death becomes more real with serious illness such as cancer or a heart attack.

Many are separated from life’s natural end points. Most do not hunt or personally slaughter animals for food. Instead, we buy chicken at Kroger or Chick-fil-A. And too often people end their lives in a hospital bed or a nursing home rather than their own home.

Science has driven our culture since the Enlightenment, and sometimes people have unrealistic expectations about disease treatment or cure. Philosophically, spiritually and scientifically, I am opposed to late term abortion because I believe all human life is precious and sacred. However, as a doctor, I am often called to explain to patients and their families the difference between what treatment is medically possible, and the futility of some interventions. Sometimes more chemotherapy, more surgery or feeding tubes will not help and will actually prolong suffering. As a Christian I do not fear death, only the dying process and the inevitable separation from loved ones.

In the high middle ages of Europe, lodging for travelers, pilgrims or the underprivileged was often provided by Roman Catholic orders in places of hospitality known as hospices. Later, hospices also became places for the sick, wounded or those dying.

The modern hospice movement began in 1967 when nurse, physician and social worker, Cicely Saunders created in England the first hospice care option for patients. The focus of hospice care is on palliation, rather than curing patients who are terminally ill. Interestingly, terminal illness is somewhat arbitrarily defined as someone not expected to live more than six months. Though more controversial, some have even advocated palliative hospice care for patients with chronic illnesses like multiple sclerosis. Hospice care is usually provided in the patient’s home rather than a hospital, and importantly, hospice care also addresses the emotional and spiritual needs of the patient as well as the needs of their family.

In my forty plus years of medicine, I can’t remember an instance of a family who was dissatisfied with hospice care for their terminal loved one. Though none of us wishes to die, it is inevitable that we all will “cross the bar” as Alfred Lord Tennyson wrote in his poetic elegy about death.

In my observations of illness and death, I remain mystified why the life force beats so strongly in some and less so in others. I’ve had patients go to sleep, terminally, in their Lazy Boy chair after their favorite dinner, while others cling to life in pain or disconnected from reality. We all desire a long and good life, but if there comes a time when I am longer any good for myself or anyone else, it will be time for me to heed the Bard’s words and “shuffle off this mortal coil.”

I do not believe in euthanasia. The word means good death, derived from the Greek words eu (good) and thanos (death). Suicide is the term used when someone takes their own life. It is against the law since we consider someone attempting suicide as irrational or out of their mind. But is that necessarily true? Likewise, it is against the law to commit murder or kill another person. Some get around this by declaring the unborn as “not a person.” Laws allowing physicians to participate in euthanasia have been passed in the Netherlands and Belgium. In other countries and states like Oregon, Vermont and Washington euthanasia is legalized under the wording “assisted suicide.”

Though I have never been a part of euthanasia, I have pushed safety limits when medicating terminally ill patients in pain. I remember promising a patient with advanced prostate cancer that I wouldn’t allow him to suffer. I admitted him to the hospital one night when his home pain protocol failed. I found him in his hospital bed surrounded by his family, writhing in pain. As I slowly injected morphine intravenously, his agony subsided, his breathing calmed and fifteen minutes later he died. His agony was holding him captive and when alleviated, he let go and met his maker.

People sometimes misunderstand therapies such as ventilators or even feeding tubes. Medically and ethically, there is no difference between starting or stopping such therapeutic modalities, and patients are free to make decisions to start or stop such treatments. I once cared for a older woman with end stage COPD who ended up on a ventilator. Our team of doctors and specialists were unable to wean her from the machine and after two months she wanted to be removed from the ventilator, knowing that she would die without it. The psychiatrist found her sane and I found her request, to end a lingering and painful existence, rational. After saying goodbye to everyone, I turned off the ventilator and this courageous woman died. So, theoretically, I participated in assisted suicide, years before such a definition and laws were enacted.

At his trial for treason, Socrates said they could put him to death, but two outcomes were possible. He would blink into oblivion or he would awaken in paradise and meet his hero, Homer. Someday, I hope to thank Socrates for such wise counsel.

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