Death is Not the Worst Thing

Filed under: by: Hey Doc Wait

Death is final. It is scary. There's no turning back. It may be painful, but then again, only the living can feel pain.

It is also going to happen to all of us. With 100% certainty, I can say that I will die someday. You will die someday. All of my patients will die someday, some sooner rather than later.

I quit looking at medical treatment as "saving lives" a long time ago, if I ever did. We postpone death, that is all. Hopefully, when we delay the reaper, we buy the patient a little time that is good. If we're really lucky, we buy them a lot of good time--hence the reason people still go into pediatrics, even though the pay sucks (for a medical specialty).

And if the time left is not good, have we done the patient any favors by keeping them alive?

This is a tough question to answer. Utilitarians attempt to answer this by using "QALY"s and working out long, complicated formulas. Ultimately, I think only the patient can answer this. I might look at the way a patient lives and think "I would never want to be alive in those circumstances", but I don't necessarily know if the patient agrees.


If a patient has made an advanced directive that states they would not want to be artificially kept alive, and has never made a statement to the contrary, and has multi-organ failure with multiple serious infections resistant to most major antibiotics, and is kept alive on a ventilator, and is in constant pain, then death is not the greater evil. This shell of a person is not your loved one any more. The constant sepsis and hypotension have destroyed the brain parenchyma wherein lived the intellect that made them who they were. If there is such a thing as a soul, where is it now? If you believe in an afterlife, is the soul stuck clinging to this wretched body, unable to go to a better place? Or, is the soul already departed, meaning that the body is just a body?

For a country in which a majority of people believe in Heaven or an afterlife, we are also utterly terrified of death. If it's such a lovely place, why are we as a culture so afraid? Medical science can sometimes keep a body "alive" for great lengths of time, but what kind of life is it spent in the ICU? If there is no mind left, no soul, then why are we prolonging this kind of suffering?

And, to be utterly callous, why are we paying for it?

In the ICU setting, one of the functions of the doctor in training should be how to greet death with a patient. How to discuss the end of life with patients and families, how to properly address risks, how to explain the limits of our care and the limitations of our science. I am not talking about euthanasia here--I don't really know how I feel about that, but it's not an issue where I live. I am talking about when to withdraw treatments and when to never initiate them in the first place. Just because we CAN dialyze the 95 year old with advanced dementia (not oriented to self) and multi-organ failure doesn't mean it is indicated. And if the patient has an advanced directive and has never made clear statements to contradict it, we should obey their wishes no matter how many lawsuits their relatives threaten--and we should be protected from lawsuits in these cases.

At some point, actively prolonging a terrible life should not be our goal, and we should be taught that we don't always have to prolong life. After all, prolonging life is not saving it.