Javier was a heavyset 78-year-old man, remarkably edematous and exhausted, suffering from congestive heart failure. He had been seen by his primary care physician and sent to the emergency department for his difficulty breathing and hypotension. His vigilant son provided the history of the 3-month battle Javier had been waging between heart failure and fluid retention. His son was well versed in the treatment regimen and intended diuresis, but had little awareness that this best practice of medicine was inflicting undue suffering on Javier. Sadly, the son was not prepared for any discussion regarding appropriate end-of-life care for his father. Obviously, Javier’s physician had been ill-prepared to address these matters of the heart pertaining to life and death.
Most physicians simply do not know how to talk with patients about dying. Those dying are more likely to be sent to the emergency department and subsequently admitted to the hospital or ICU. Essentially, patients have to figure out for themselves how or when to die due to physicians’ ignorance. Patients are encouraged to fill out advance directives and Medicare now pays physicians to assist in the process. However, Javier’s all-too-familiar predicament is not typically addressed in these documents until he becomes incompetent or experiences cardiac arrest. Truly, these documents are never a substitute for having heart-to-heart conversations between patients and their caregivers about crossing the finish line long before exhaustion or sudden death ensues.
Lack of medical education has been cited as the reason for physicians’ mismanagement of end-of-life care. However, the end-of-life journey is a spiritual undertaking for patients and this has been overshadowed by the use of fearful medical terminology like “terminal sedation” or “death through starvation” – used to describe heartfelt provisions of compassion, dignity and unconditional love. Physicians need much more spiritual training and guidance in these matters, but not through curriculums. They need to listen to their own hearts – the voice of humility. Through an evidence-based perspective, humility is weakness. While as a quality of respect for others, humility is a heart-based initiative.
Physicians are more likely to tell patients what to do and rarely have patients actually think from their hearts. Near the end of life, a physician might ask, “What are your wishes?” Panic-stricken, most patients and their caregivers call for everything to be done to sustain their lives. Many physicians feel this is wrong, yet are less inclined to disagree with their patients’ wishes and provide opposing insights from their own hearts. Physicians and patients have one-track minds toward measures of hope that promise little or no improvement. When the medical condition has a poor prognosis, a spiritual connection between physicians and patients is needed to address these heart-wrenching, life-and-death concerns.
Wishes To Die For is a personal example of a physician who has examined the heart of his patients, contemplated his own wishes and shared these matters with other caregivers to ponder. The medical school model of “See one, Do one, Teach one” is how physicians learn to practice medicine. The same methodology could be used to incorporate this physician’s self-prescribed version of humility into the purposeful intention to do no harm. Being true to the heart in matters of spirituality is not an intellectual practice, but enlists the necessary virtues of integrity and intuition. The certainty of being right, described as dignity in this book, instills a profound truth and intuitive reasoning which aid the decision-making process.
Advance care directives offer little insight into how to best address patients’ end-of-life care. These documents do not pose the right questions or address the inherent conflicts between a patient’s mind, body and spirit. Reconciling these conflicts is both a personal and professional dilemma for physicians, requiring empathy and enlightenment. Achieving resolution in life-and-death discussions involves the distinction between quality of life and quality of death. Having patients consider their quality of death may actually begin with physicians coming to terms with the essential message of the Serenity Prayer. The wisdom to know the difference between acceptance and courage is fundamental to end-of-life care.
Most physicians do not know how to properly treat patients at the end of life due to primarily focusing on them as diseased human beings. The end of life is not a medical condition – it’s a spiritual journey. Patients at the end of life need to be respected as spiritual beings. Wishes To Die For is the personal diary and outcry of one physician to other caregivers to treat others as they would treat themselves – as a gift from God. The collective duty of caregivers is to return this gift to God unharmed. Spiritual beings have a light that shines through them and healthcare decisions need to surely be illuminated by compassionate physicians who practice medicine from the heart.