Any week spent working nights in a hospital intensive care unit is sure to be memorable, but my first week of ICU nights as a resident physician in 2019 brought a particularly memorable “first.” It was the first time I ever exercised my medical authority over death.
During medical school and early residency, I encountered several patients who passed away while I was part of their care team, or shortly thereafter. But Ms. G was the first to pass while I was the first-line physician caring for her. Her death was not unexpected. A woman in her 60s, she had dealt with ovarian cancer for years, including one especially problematic metastasis which pressed on the ureter running from her left kidney to her bladder. This led to recurrent severe urinary tract infections, several of which had landed her in the hospital previously, but aggressive medical care had always pulled her through. On this occasion, she had felt weak and short of breath at home and had called an ambulance, but when paramedics arrived they found her minimally responsive, her heart beating dangerously slowly, and then it stopped entirely.
8 minutes of CPR brought back her heartbeat, and she was intubated and placed on a ventilator to keep her breathing, given fluids and antibiotics to treat her infection, and admitted to our ICU. But then she had several seizures with full body stiffening and convulsions, a very bad sign suggesting that when her heart had stopped serious brain damage may have occurred due to lack of blood flow. The hospital team kept her deeply sedated and cooled her whole body for several days to slow her metabolism and try to minimize neurologic damage, but when she was re-warmed and the sedating medicines were weaned off, she remained unresponsive. An MRI of her head confirmed our fears: widespread anoxic brain injury. Enormous areas of her brain were severely damaged beyond any chance of recovery. While she was not technically brain dead, the most she could reasonably hope to recover would be some rudimentary semi-purposeful movements in response to touch or voice. The higher human functions of language, emotion, reason, and personality had been irreparably disrupted, and there was no realistic possibility of regaining her life as she had lived before.
We carefully shared this sobering news with her family. Her husband had passed away just a few months earlier, and so her son and daughter were given the heavy task of processing this wrenching prognosis and determining what their mother would want done. It was clear that she would never be fully herself again, and any degree of partial recovery would only happen with many, many months of suffering on a ventilator, as her brain was too impaired to reliably keep her breathing without support. The family decided that Ms. G would not want to go on like that. She had lived a good life, fought long enough with cancer, and now lost her husband, and she would want them to let her go. Extended family gathered from out of town, and plans were made for terminal extubation; to remove the ventilator breathing tube and let nature take its course.[1]
It took its course at 5:01 a.m. on my night shift, 15 hours after the day team had taken her off the ventilator. She had been kept comfortable and peaceful through the afternoon, evening, and night with palliative medications, and her son and daughter had remained at her bedside the whole time. Around dawn the bedside nurse came into the ICU workroom and informed me that he had just checked on Ms. G and found that she was no longer breathing and had no pulse. I suddenly realized that it now fell to me to officially pronounce her dead.
Medical training is full of many, “Woah, I’ve never done this before” moments, but this one hit particularly hard. I have authority over death? 29 years old, M.D. diploma less than 1 year old, 1st year neurology resident on my first ICU rotation, and I have power to declare with finality that a fellow human being has, and is, departed? Can I really do that?
For better or worse, night shift in the ICU allows little time for rumination, so after counseling briefly with an experienced ICU nurse practitioner, I went to the room, alone. Ms. G’s son and daughter stood beside her bed, their grief somewhat subdued by their long night vigil. I quietly informed them of my purpose in visiting, and they chose to remain in the room. I approached the bed, held Ms. G’s wrist and felt for a pulse, and found none. I pulled out my stethoscope, pressed it to her chest and listened for heart and lung sounds, and heard none. She lay utterly still, no response whatsoever to my voice or touch. I drew back, offered my sympathies, and walked back to the workroom. There I dictated a note recording the time of death and describing my exam findings, and entered the final order in Ms. G’s electronic health record: “Discharge as Deceased.” And that was it.
Almost anyone can inspect an immobile body and conclude that the person is dead, but as a physician, when I say a person is dead, it’s official. It goes on records kept by the hospital, city, state, and country, and usually nobody questions my authority on the matter. But where did I get that authority? Where does authority over death even come from? Spending years studying the workings of the human body and its myriad processes and dysfunctions, followed by decades observing, examining, and treating patients gradually gives experience which justifies some authority to speak and act on matters of health and illness. Along the way this medical authority is made official by various stamps of approval: Doctor of Medicine, License to Practice Medicine, Completion of Residency, Fellow of the American Academy of Psychiatry and Neurology, Maintenance of Certification, etc. And that seems sensible. But what about authority over life and death? That is not the same thing.
For one thing, what is death? In declaring Ms. G dead, I used the cardiopulmonary standard: death is the irreversible cessation of heart and lung function. Since prehistoric times, humans have noted that many organs can cause problems if damaged, but if the heart and lungs stop working, the rest of the body permanently stops working. It’s a clear definition, and it’s as simple to apply as my exam of Ms. G. But then humans invented ventilators which breathe for the patient, and cardiac devices which pump blood for the patient, and now we have extracorporeal membrane oxygenation (ECMO) which does both. For patients who are on these sorts of life support and are severely neurologically injured, physicians sometimes apply the neuro-respiratory standard of brain death: death is the permanent loss of capacity for consciousness, spontaneous breathing, and brainstem reflexes.[2] Applying this definition is a little more complex and involves testing various brainstem reflexes that control eye movements, coughing, and breathing, but it allows us to say objectively whether or not a patient is “brain dead.” But then there exists a broad spectrum of patients who are somewhere between consciously living and brain dead: severely and irreversibly brain damaged, but maintaining some basic brain functions and reflexes. And there is a far larger group of “chronic critical illness” patients, whose brains are relatively intact but who have a lengthy and growing list of severe incurable diseases with multiple organs failing, and who are only kept partially functioning by medical interventions which grow steadily more aggressive, invasive, and frequent. Are these patients dead? Not according to either of these 2 standard definitions which physicians use. And thanks to ventilators and many other remarkable machines, barring a crisis we can keep patients semi-stable in such states for a very, very long time.
And by default, we do. Physicians most often exercise their authority over death by fighting against it. We ponder and struggle over which treatment to apply to critically ill patients, but the question of whether to apply a treatment may be forgotten, ignored, or actively rejected. Part of this reaction arises from a genuinely noble determination to “do everything” to relieve disease, pain, and suffering. But part of it is less noble and more human. Treating disease is the default course of action in medicine, and human psychology always leans toward sticking with the default rather than making a deliberate choice to deviate from it.[3] A doctor may also have built their identity on being a savior of lives, with death framed as failure and defeat. And a doctor who has not come to terms with their own mortality may see it reflected in the eyes of a dying patient, and react desperately in fighting against it.
And then there are the pleas of the patient and family: can’t you do something? Isn’t there still a chance? Keep doing everything, we can’t just let Mom die. In the modern culture of exalted science, hospitals have become the temples of healing where the ill and dying come seeking scientific blessings of renewed life from priests in white robes. It is the same impulse that has always driven humans to call upon higher powers: in a world of uncertainty we yearn desperately for something certain, reliable, and powerful in which to place our trust. But science makes a poor deity, for it is founded in questions rather than answers, and at its glorious best it is a patchwork of theories, corrections, contradictions, and uncertainties, where fragments of glimmering truth are agonizingly difficult to identify in a sea of competing hypotheses.
The great physician William Osler wrote, “Medicine is a science of uncertainty and an art of probability.” [4] Nowhere is scientific uncertainty more prominent than in medicine, where the fundamental uncertainty of physics is amplified through layers of chemistry, biology, physiology, and behavior into the beautiful complexity of a human being, whose individual response to treatment can be known only by passage of time, and whose only certainty is eventual death. But a caring doctor doesn’t want to burden the suffering patient with the full weight of medical uncertainty. The patient might panic. They might lose hope. They might lose faith in their licensed clinicians and turn to far more dubious healers. And so we try to balance acknowledging the unknown with presenting our best coherent explanations and recommendations for treatment.
Understandably, many patients and families given this balanced presentation ask for more certainty: will this get better? Will it get worse? How long do I have left? In response I try to provide reliable data from the medical literature, but I emphasize that medicine does not offer certainties, only probabilities, and these drawn of necessity from large groups of patients who are similar enough to be statistically useful and yet varied enough to undermine prediction of outcomes for any individual. When patients accept that I as a physician have very limited ability to predict the future, it always seems to include some degree of disappointment. They came looking for answers, and while a diagnostic explanation for their symptoms and a plan for their treatment is nice, I often sense the larger questions pushing from behind the curtain: why did this happen to me? How is this going to affect my life? Will this end my life? If so, what happens after that?
I feel obligated to stick to my white-coated role of medical scientist, but when I sense those larger questions looming behind patients’ inquires and concerns, I feel constrained, like Jacob Marley’s ghost from Dickens’ A Christmas Carol. When Scrooge is confronted by a haunting vision of the afterlife and asks in distress, “Tell me more, speak comfort to me, Jacob!” his deceased, chained business partner replies, “I have none to give. It comes from other regions, Ebenezer Scrooge, and is conveyed by other ministers”. [5] My patients are far worthier than Scrooge to receive answers and comfort, but when it comes to life and death, in my role as physician I have no more ability to provide eternal answers and true comfort than damned Jacob Marley. Any patient who seeks to understand life and death in a medical clinic or hospital is in a terrible predicament: confronting the abyss surrounded by those who have nothing useful to say about it. [6] I can politely ask what sources they have turned to for comfort and spiritual strength in the past, but when such sources seem to be lacking or absent, it makes me want to take the white coat off, set it aside for a few minutes, and share where I go looking for answers and comfort, what I have learned, and invite them to learn for themselves. So far I haven’t figured out how to appropriately work this into my medical practice without crossing boundaries and disrupting care, but here is what I might say if I could:
I sense that what you are really asking for isn’t another medical statistic. You are looking for certain answers about life, suffering, death, and purpose. As a doctor I don’t have the answers to those kinds of questions, but I have personally learned that there is a God who does. God is the true authority over life and death. God formed your physical body and understands it completely. God knew you before you came to Earth, and is intimately aware of what you are going through right now. God sent you here to provide you opportunities to learn, make choices, gain experience, and overcome challenges. Knowing this would be impossible to do by yourself, God sent Jesus Christ to teach truth, exemplify goodness, experience the worst of all human suffering, and overcome death. While our bodies will gradually break down and eventually pass away, through Jesus Christ you will be resurrected, your body restored to life and raised to a new Life that can never die. Life continues on, not in metaphor or memory or mystical essence, but in physical reality, for that is the only way you could still be you.
I know this is true, not through my medical training, but by inspiration from God through the Holy Spirit. I was taught about Jesus Christ and the resurrection by my parents, but I learned for myself in April 2010 while listening to an inspired speaker, Thomas S. Monson. He spoke of seeing the painting “A Hopeless Dawn” in the Tate art gallery, [7] which shows a woman mourning the loss of her husband at sea:
Monson spoke: “Among all the facts of mortality, none is so certain as its end. Death comes to all; it is our ‘universal heritage; it may claim its victim[s] in infancy or youth, [it may visit] in the period of life’s prime, or its summons may be deferred until the snows of age have gathered upon the … head; it may befall as the result of accident or disease, … or … through natural causes; but come it must.’ It inevitably represents a painful loss of association and, particularly in the young, a crushing blow to dreams unrealized, ambitions unfulfilled, and hopes vanquished.
“What mortal being, faced with the loss of a loved one or, indeed, standing himself or herself on the threshold of infinity, has not pondered what lies beyond the veil which separates the seen from the unseen? Centuries ago the man Job—so long blessed with every material gift, only to find himself sorely afflicted by all that can befall a human being—sat with his companions and uttered the timeless, ageless question, “If a man die, shall he live again?” …
Monson then recounted God’s plan of salvation, the life, suffering, and crucifixion of Jesus Christ, and said: “No words in Christendom mean more to me than those spoken by the angel to the weeping Mary Magdalene [at the tomb] … ‘Why seek ye the living among the dead? He is not here, but is risen.’
“Our Savior lived again. The most glorious, comforting, and reassuring of all events of human history had taken place—the victory over death. The pain and agony of Gethsemane and Calvary had been wiped away. The salvation of mankind had been secured. The Fall of Adam had been reclaimed.
The empty tomb that first Easter morning was the answer to Job’s question, “If a man die, shall he live again?” To all within the sound of my voice, I declare, If a man die, he shall live again. We know, for we have the light of revealed truth. “For since by man came death, by man came also the resurrection of the dead. For as in Adam all die, even so in Christ shall all be made alive.” [8]
I was 20 years old when I heard these words, serving in Korea as a missionary for The Church of Jesus Christ of Latter-day Saints. I had long loved hearing Thomas Monson’s stories and testimony, but when he said, “I declare, if a man die, he shall live again. We know,” something resounded inside me, and a thought filled my mind with striking clarity, “This is true. Resurrection is real.” It was clear and certain, distinct from ordinary thoughts and emotions originating from within myself, and as powerful as any inspiration I had ever experienced. From that moment, I could count the resurrection of Jesus Christ, and of all God’s children, as one of the foundational gospel truths of which I have a sure, personal witness.[9]
As I passed through medical school and residency training, this certainty about Life after death made a profound difference in each encounter with human morbidity and mortality. It came to my mind again as I pronounced Ms. G dead, knowing even as I signed the note that my words would be overridden by the One who has true authority over life and death, the Life and Light of the world. I have often wondered how anyone can tolerate working in the medical field without some hope beyond what medical science has to offer. Enjoying life’s simple pleasures now and living on in fond memories later isn’t good enough, it just doesn’t hold a candle to eternal progression here and hereafter. So many times I have wanted to share my own source of hope with patients and colleagues. To those who find resurrection unlikely or even absurd, I would share the words of Lawrence Corbridge:
“While it is understandable that we may be challenged by the extraordinary, we shouldn’t be, because ordinary things are actually far more phenomenal.
“The most phenomenal occurrences of all time and eternity—the most amazing wonders, the most astounding, awesome developments—are the most common and widely recognized. They include: I am; you are; we are; and all that we perceive exists as well, from subatomic particles to the farthest reaches of the cosmos and everything in between, including all of the wonders of life. Is there anything greater than those ordinary realities? No. Nothing else even comes close. You can’t begin to imagine, much less describe, anything greater than what already is.
“In light of what is, nothing else should surprise us. It should be easy to believe that with God all things are possible.
“The healing of the withered hand is not nearly as amazing as the existence of the hand in the first place. If it exists, it follows that it can certainly be fixed when it is broken. The greater event is not in its healing but in its creation.
“More phenomenal than resurrection is birth. The greater wonder is not that life, having once existed, could come again but that it ever exists at all.
“More amazing than raising the dead is that we live at all. A silent heart that beats again is not nearly as amazing as the heart that beats within your breast right now.” [10]
I know this is true. [11] It is so real and comforting and exhilarating that I want to shout it from the rooftops and help everyone I meet to learn for themselves that it is true. I don’t know how to do that, but writing a blog post seemed like one useful approach. For anyone who is curious to know more, there is nothing I would be more happy to discuss and share together.
Marcus Callister
Last updated 03/29/2023
References :
[1] Terminal extubation is a morally charged topic. I have much respect for those whose religious or moral framework leads them to decline to participate in it. I personally believe it is an ethical option in specific situations, including the one described, and that a key factor is what the patient would choose if they could. In this case, the attending physician Dr. S had told the family them that in these situations there was no right or wrong answer for everyone. He had encountered patients who had written wishes that, “as long as I can watch my favorite TV channel, I’m fine with being kept alive hooked up to a ventilator or any other machines indefinitely.” He had met other patients who declined to even go on intermittent hemodialysis because, “Then I’d be tied to the hospital every other day and I couldn’t go out hiking for weeks in the wilderness anymore, and if I can’t do that then I’d prefer to pass away in peace.” The difficulty, of course, was that most people fell somewhere between these two extremes, often along the lines of, “I’m OK with being on mechanical support for a short time to save my life, but I don’t want to be stuck half-dead on artificial life support forever.” The family decided Ms. G was in this group. I may write further about end-of-life decision-making in a future post.
[2] https://n.neurology.org/content/98/13/532
[3] See Daniel Kahneman, Thinking Fast and Slow
[4] The Quotable Osler, American College of Physicians, Philadelphia, PA, 2003.
[5] Charles Dickens, A Christmas Carol, Stave 1
[6] With one notable class of exceptions: there are members of the healthcare team who are trained and enabled to help patients work through issues of life, death, suffering, and purpose, and these are the chaplains. I love and respect the work they do, engaging in deep reflective listening and sharing spiritual encouragement suited to the patient’s own belief system without proselytizing. Unfortunately, in most healthcare settings they are involved in only a minority of patients’ care, mostly those who already have some religious faith or spiritual inclinations, and patients without spiritual resources or interest are the least likely to see a chaplain, even though I believe they are the ones who could benefit the most. I also reject the notion that only chaplains should engage with patients on spiritual matters: while aggressive preaching to patients in difficult and vulnerable situations raises ethical concerns, what I see far more often are patients expressing some spiritual desire and hope, and their medical team becoming awkwardly silent and then changing the subject, instead of embracing and encouraging the patient’s spirituality as a vital part of their care and wellbeing. A chaplain referral is nice, but I also want to appropriately connect with my patients’ spiritual health, just as I connect with their physical and social determinants of health. In Dallas, I met clinicians who regularly offered to pray with and for their patients, I admire them greatly and would like to work up the courage and finesse to do similar.
[7] https://www.tate.org.uk/art/artworks/bramley-a-hopeless-dawn-n01627
[8] https://www.churchofjesuschrist.org/study/general-conference/2010/04/he-is-risen?lang=eng
[9] See separate blog post “My Postulates” for the full list
[10] https://speeches.byu.edu/talks/lawrence-e-corbridge/stand-for-ever/
[11] A thoughtful modern reader may ask, “Isn’t faith like yours just wishful thinking that has been reinforced by emotional placebos to the point that it is self-perpetuating?” I would answer that as a neurologist I am deeply aware of and fascinated by the inner workings of the human brain, including confirmation bias and construction of emotions. The key difference I find between self-deception and spiritual truth is in the fruit they bear: the former can be preserved only by self-defensive insulation, while the latter grows stronger as it connects with other related truths and brings ever greater insight and understanding. I have many thoughts on this subject and will prioritize it for a future post.