Last Rites

My mother is amazed that I'm a doctor. She is amazed at the things that doctors go through. It's a charming sort of attitude that manifests itself in comments like "You're so young to be dealing with all this heavy stuff."

She's right, in a way: I'm thirty-three going on a hundred some days.  Those are the days when I tuck my kids into bed, or bring them to the hospital with me, and I sit down and talk seriously with family members. The days when my spouse hears "I'll be there inside of twenty minutes" and sets his expectations that he'll be going to bed alone. The days where I dine with death, and walk the halls with death, and sit vigil waiting for death to come. Those are the days when I only know that I don't know what it's supposed to be like to be thirty-something, but I'm pretty certain it doesn't involve asking someone's sons and daughters how hard I am supposed to be trying to save a life.

The easy nights, when I have come so far as to ask that question, are the ones with tears and tissues and hugs and half-formed sentences.   Those are the nights where I know that I may not be able to cure what's wrong, but I can still heal something. I can do what is in my power to ease pain, and answer questions honestly, and I can be the one to say the things that I can see in everyone's eyes. Those are the easy nights, when death is quiet, and sits by the bedside holding someone's hand, and waits.

I have had this conversation before: by now I have had it a hundred times. I still tear up, and reach for my own tissue from the communal box. I still mourn. I hope I always do. It is hard to let go of someone -- it is hard to step away from your own self and grant another person the freedom to die if they choose, without trying to nail them to life.

Sometimes, there are hard nights. Those are the nights when decisions come too hard, and there are codes and chemicals and pressors and antibiotics and machines: we set great store by our machines, we doctors. We have machines to breathe for you and machines to pump your blood for you and machines that take the place of hearts and kidneys and lungs and stomachs.

But we have no machines to replace the soul.

Call it what you will: a life force, the essential energy of being, the will to live, the soul, the animus, God within. By any name, it is the thing that animates us, that makes a pile of blood and bone and flesh and synapses a person. It is the thing that makes us be, and it is the thing that leaves when we stop being. And I have seen its struggles, like a butterfly on a pin, on the altar of technology, vivisected by the hands of medicine.

Just because we can does not mean we should. There are some things that are universal: when the thing within desires to live, then we should support it: that is the time for machines, and for technology, and for the doing of heroic deeds. That is the time for the saving of lives. But when it is finished, then we should let it go. We should let it slip as gracefully away as we can; we should practice the art of medicine and the art of healing -- which is not the same as the art of fixing things. And we should look for peace, where we can.

When we have reached the point of this conversation, it is rarely a surprise to anyone that it is occurring. I can see it in the eyes, and the crumpled tissues, and the lingering touches. But it is not my doing that will decide whether a person lives or dies, and that seems sometimes to come as a surprise. I tell families that I can start pressors to raise the blood pressure, and ventilators to keep the air moving, and I can call the big city doctors at their big city hospitals and I can find an ICU bed, and we can keep the body alive, but that does not decide when a person dies. Only the person -- only that animate thing within them -- knows when it is ready to go. And without it, a body is nothing but a body.

Sometimes, I have this conversation, and there is agreement, and then people get better. They go home. They see their families again, and they stretch out their lives another week, or month, or year, or decade. Sometimes, they don't. There's no science that I can divine that says that this woman will recover from the point of death, while this man will not. I tell families that, too. I tell them I don't know what's going to happen. But I tell them if I think something will happen soon.

That's the best I can do.