Approaching Death

The ideologies surrounding mortality have been surfacing far more often than they used to in my consciousness. In my medical training, I saw countless people cheat death, avoid it by lowering their standard of living through medical treatment, and a few others embrace it gracefully. Here in Ethiopia, my role in death is challenged almost daily.

My training has produced a “surgical mentality” in that when a problem is presented to me, I face the challenge head on completely expecting to make it better. If someone has a problem, then I can fix it. If I can’t, I know someone who can. This is what Head and Neck surgery training in the United States taught me. When a patient passed away from a terrible disease, it was simply accepted as the only inevitable outcome.

Here, I’m presented with a 30year old who has been letting squamous cell carcinoma grow in his neck for 4 years with a tumor burden that would be deemed unresectable by most. Due to the sheer volume of disease, I know in my heart that even with the best chemoradiation, this disease would persist. And by exposing his entire neck, mouth, nose, and eyes to radiation the ensuing damage would drive down his standard of living so low as to question the point of experiencing life. Should I give him the best shot at living by performing a radical dissection and then exposing him to chemoradiation? Would the years he gain from such radical treatment be worth it? The patient, his family and our team together are the only ones to answer these questions and there are no good answers. The question that should be posed is: How do you want to die?

This topic has always persisted in my brain, but last year I decided to pay attention to it. A friend suggested I read “Being Mortal” by Atul Gawande. A surgeon’s perspective of a medical crisis in the united states: how we treat our dying. It surfaced for me a concept of terminally ill medical care vs the desires of the terminally ill. Fix what’s broken that’s the cardinal law of my training, but this is not always true. What I have recently learned is that my role is to do everything possible unless it interferes with the way the individual sees themselves dying. For that truth supersedes any medical training we may have.

So, the question is posed again: How do you want to die? Staring eye-to-eye with this 30 year old man, I understand the hesitation to answer. He has no idea. I’m older than him, I think about this often and I still have no idea how I want to die.

As a western trained doctor here in Mekelle, the perception from some of the public is that I can fix anything. If not with my own skill, then will a pill or piece of technology from the states. A local friend I made last week asked me to visit his friend’s mother in the hospital to see if I could fix her. An elderly woman, struggling to breathe, pitting edema, lungs sounding underwater and an ECHO with an ejection fraction in the 30s. There was certainly nothing I could do and from the notes in the chart, the medical team was doing everything they could do. She was dying of congestive heart failure and I had seen this story many times before.

Over recent years my grandmother has been struggling with congestive heart failure as well. My mother (this is my mom’s mom) and I have been discussing the dilemma of personal independence vs medical treatment for the last couple of months. It was becoming clear that my grandmother will need to answer that oh-so-vital question. Inevitably, last week she developed progressively worsening symptoms and was sent to the hospital and admitted for a CHF exacerbation. Confused and clearly unhappy, the family decided to fulfill her wish to pass her remaining time at home with familiar surroundings. Hours after establishing home hospice, she peacefully passed away in her sleep; perhaps the most ideal way possible. This was the afternoon of September 5th.

I wasn’t able to speak to my mother until the next morning after she flew down to Florida. On the phone, while attempting to choke back tears she reveals that my grandmother’s husband also passed away on the afternoon of September 5th, many years ago. Her words painted a mental picture of an ethereal meeting of the two of them, locked in a long-awaited, gleeful embrace.  As a final gift to me, my grandmother has given me an answer to that question: I want to die like she did.

Devastating events such as this demand a halt in life for introspective analysis. What am I doing in life? Am I using my time in life wisely? Should I be home holding my mom’s hand through this very difficult time?

Months ago, during the last real conversation I had with my grandmother before she had difficulties with cognition, I revealed my intentions to move to Ethiopia and why. Her reaction was more supportive than anything I had done before. The joy I heard in her voice and the smile I imagined on her face filled me with pride. Her enthusiasm empowers me now and I know my dedication here gives her pride. I will miss her always. Thank you for teaching me one of life’s most important lessons.

Rest In Peace Grammy.

family at FDR

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