On Death and Dying, by Dr. Elizabeth Kubler-Ross

This summer, I began reading a book that gave me a new viewpoint on the medical profession. I certainly won’t craft my entire focus around it, but it gave me some interesting perspectives…

On Death and Dying is a book written by a psychiatrist, Dr. Elizabeth Kubler-Ross, who recounts the information she has gained through her interactions with terminally ill people and patients. At first she introduces the reader to the familiar side of the profession, with its research and the general humanity found in saving lives, the years of medical school, and the traditional mentality of doctors. However, she also mentions a side most people don’t think about: that prolonging life may not be equivalent to saving it.

She begins by talking about the denial of death that patients felt, resorting to various coping mechanisms when they learn of their impending fate. This denial is not exclusively for the terminally ill, however. Most people feel this way, because the concept of death is inconceivable for the human mind. She also proposes the idea that in common healthcare practices, refusal to acknowledge the patients’ wants and needs is an attempt to dehumanize the situation, resulting in avoidance of facing death. During operations, a patient is treated like a machine, and their comforts and desires are not considered. This absorption of the doctors into the mechanical aspects is an attempt to distract themselves from facing death that is reflected in the patient.

I also learned that fear of death is often associated with fear of being forgotten. This stands in line with what I have learned in evolutionary biology, the concept of existing solely to survive and reproduce. While that remains a heavily simplified version of human existence, it lives at our core. By surviving and reproducing, we ensure that a part of us continues on, and fear of leaving this Earth is mitigated slightly.

http://www.sfgate.com/news/article/Expert-On-Death-Faces-Her-Own-Death-Kubler-Ross-2837216.php

Dr. Kubler-Ross had to face her own death at some point, and did not take it well. However, her own experience with death and dying patients supports her own reaction, and its important for us to realize that. She mentions in this article that she doubted whether her nurses or anyone had seen her life’s work after they treated her in the manner that they did. Well, I wish to take that viewpoint and use her life’s work in my own practice. This book and Dr. Kubler-Ross’ history have shown me a different side of medicine: a side that defies the conventional beliefs of prolonging life, and focuses on the patient’s wellbeing. Hopefully, more people read this book, and take away from it that fear of death can only be overwhelmed by confronting it.

November 20th Update:


For the longest time, I had a paralyzing fear of death. I’ve woken up screaming, and have held a constant fear over my shoulder because of it. Reading this book was an attempt to overcome it, yet the article about Kubler-Ross’s difficulty facing her own death seemed like the ultimate paradox, and may have triggered my panic again. However, on October 2nd, I experienced a revelation…

I was in a dream, and sitting in a semi-large white room with no decorations save for a TV. Around me in the other chairs were the people I had hated most throughout my life. There were about 5 of them, and they were the cruelest people I knew. They were the ones that had bullied me, had tried to put me down, prop themselves up as leaders. These were the popular kids, from which you would expect nothing but happiness and kindness, the figureheads of student government. I burned with hatred, but was interrupted by a door opening and a man walking in with a white lab coat and a mask over his head. He told us we were all sentenced to die, and would do so with lethal injection. So he injected all of us individually and we waited to die. We didn’t know when, but we knew we would. We started watching TV, all the fight drained of us. As the symptoms began to kick in, we started to get cloudy vision, and I looked around at the people with me.

I felt no hatred. I wasn’t thinking of my family, my sister, my life, nothing. Just in that moment. My breathing slowed and became harder, and the pain in my chest grew. I said goodbye to everyone and collapsed, only to wake up in bed. I would like to say that in that dream, I died. And I felt no fear from dying because I had no regrets for anything. That’s when I realized death is only painful when you have regrets. Otherwise, it is about the most peaceful thing there could be. Fear is painful, death with regret is painful, but death itself is not painful.

I overcame my fear of death that day, and I started living my life differently. I still get irritated by the same things, but the fear I once had was lifted in that transformative experience. That was the day I grew up.

 

 

Lessons Learned from Shadowing and Volunteering

In addition to my two “excursions”, I also shadowed and volunteered throughout the summer. I volunteered at the Alzheimer’s Association, and shadowed at the local West Chester Hospital.

During this time, I learned on a physical and emotional level, and the lessons have stuck.

The issue I always faced, being a gung-ho debater, was motivating kids. They would practice tirelessly, but shut down during tournament time. I was a stereotypical “hot-blooded young man” when it came to debate, so getting fired up was never an issue.

However, not everyone worked that way. Especially not my debaters. That stumped me: why wouldn’t they fire up? Most people, if losing a debate, fight back with more vigor. I thought that was what everyone did.

I talked about this with my dad (naturally over a game of ping-pong), and he told me that people are different (obviously), but also that what most people want is not for me to talk to them, but for me to LISTEN TO THEM. I did listen to them, but I never to the extent that they would spit up what it was that bothered them. I was never able to do that with my kids, because by that time I was already in college, but I tried that now…

Shadowing:

Specific Experiences:

Electrocardiology: 10 hours

Pediatric Neurology: 8 hours

Otolaryngology: 5 hours

Knee, Heart, and General Surgery: 8 hours

Free Clinic Shadowing: 8 hours

Pulmonology Outpatient: 12 hours

ICU: 4 hours

Neonatal/Perinatal ICU: 2 hours

Emergency Medicine: 15 hours

Cumulative: 69 hours

Main List:

  • Cliche, I know, but professionalism applies here. I wanted to get close with the patients, to understand their problems, but that isn’t my job. My job is to leave myself out of it. Granted I will be compassionate, but if I even slip with the professionalism, a can of worms opens up in the relationship, and I put a pressure on myself where I cannot treat people properly. I must alternate between clinical and medical questions, as I have noticed that this combination gets right to the point while also building rapport. Patients may not be seen for a while (6 month+ gaps in between visits), so it is critical to be attentive and get as much as you can from each visit, so that you can build on relationships even after long absences.
  • Nobody is treated differently, regardless of whether or not they have a doctoral degree or not. I anticipated that when interacting with PhD’s in the field who came in with heart or brain problems, that we could skip some of the explanatory portions of the appointment (assuming they understood what they had). While they may know what they have, there needs to be a uniformity in the way doctors talk to their patients, and there is. They treat everyone the same, and it makes things less complicated. As such, I will do the same.
  • In outpatient (where I’ve shadowed a neurologist for a week, and this cardiologist for a week), I learned that there tend to be commonalities between every patient, or rather drugs/diseases that appear every time (from my time, it’s been Keppra for epilepsy, Coumadin, Toprol, Lisinopril, and Omeprazole for the heart, albuterol and Stiolto for anything respiratory). Of course, specifics depend on the specialty, but no doubt there appears to be a lean towards certain medications.
  • Medicine here seems to be more reactive as opposed to proactive. It’s disheartening, even though we are doing the right thing. Far fewer patients need to be here. In addition, the answer to less-than-effective medication is seemingly more aggressive medication. However, good lifestyle choices need to be emphasized and encouraged as the only ways in which medication can be effective, or else no change will occur.
  • The schedule defies the typical workweek, as generally it involves a lot of choice (again, just a conclusion from what I’ve seen). However, the hours are busy and generally exhausting, though not in a bad way. Communication with the nurses and the staff is of vital importance, and notes cannot get backed up, even if that means a bit of a delay for patients.
  • Keeping updated with software is pivotal. This is a constantly changing field. Failure to do so can result in either dependency or inadequacy, neither of which are acceptable. This isn’t something most people think about when trying to become doctors, but something they realize they have to do afterwards. As my PI said once, “That which we are not, we become”.
  • ICU functions in an interesting manner, as collaborative rounds are used and conversation and communication between doctors is critical. This is different from outpatient, as patients are not conscious often and precautions need to be taken when meeting with patients. Extensive communication among staff regarding orders, tests, and scans is required, along with a more intensive workday. This feels more congested and less laid-back than I have seen. In addition, I learned about Advanced Practice Nurses and the categories they fall into: cRNA, or Nurse Anesthetist, NS, or Nurse Specialist, NM, or Midwife, and Nurse Practitioners, which fall into two categories: Primary Care and acute. These were distinctions that I had not previously encountered and I was grateful to have my ignorance cleared. The roles of nurses blend with those of doctors, which I knew. While nurses do get patient to patient interaction, the responsibility and the final decision-making does clearly rest with the doctor, along with comprehensive knowledge of many conditions. These are reasons why I want to pursue a career as a physician as opposed to that of a nurse or any sub-specialty.
  • I was truly impressed and shocked with what I saw in the neonatal ICU. These children looked so small and fragile, and had such elaborate equipment set up that I couldn’t help but feel sorry for them. I witnessed a gastroschisis and the subsequent attempt to fix it, along with an understanding of the importance of the job and how much small actions influence future trajectory. In addition, I was able to determine more of the difference between adults and children with regards to healthcare, and how systems that work in adults completely differ in children. This includes the knowledge that fever causes temperature increases in adults but drops it in children. Because children cannot communicate, this makes the cause of the problem difficult to discern. It could be an infection, or just the window being open. Such sensitivities make this different than other specialties, which made me quite interested in it.
  • Witnessed sickle cell crisis, motor vehicle crush victim, herpes, meningitis, ultrasound of ventral hernia, vomiting, sexual assault victims, self-mutilation victim, pyelonephritis (incredibly painful), woman rushed in with accelerated breathing, man rushed in with possible brain injury, clear alcoholism issue, inability to restrain bowels. In addition, person with eye damage, pulmonary embolism, etc.

Where I learned about myself:

I was in with a patient who was rather large and struggling to breathe because of weight. Some heart tissue had died, and thus a permanent decrease in functionality had resulted, resulting in a shortness of breath. This was especially frustrating for the patient, who was not comforted by the alternative therapies option (transplant). The medication was frustrating the patient, who didn’t want to continue it even though it was the only option. This, coupled with some miscommunication from the patient’s primary care physician, resulted in much angst directed at the cardiologist and the staff despite no culpability. The cardiologist and the staff handled this completely unreasonable situation professionally, and the problem was resolved.

That brought me back to what my father said: that people aren’t mad at you, but are simply venting their frustrations onto you. You have no right to snap back.

I was already a patient individual but that’s when it all clicked.

Later on, in the Solid Tumor Clinic, I was shadowing and was faced with a heartbreaking situation: the diagnosis of cancer. This was to a person struggling with financial times, and now had relapsed. How was the patient going to handle this news? Most people don’t plan for cancer in the first place, and never want to have to plan for it after beating it once. Heck, most people can’t produce around $400 of cash at this very moment in America. The doctor handled this case as tenderly as he could. As in the previous example, he took some verbal abuse, but was incredibly kind and supportive. From this particular instance, I learned another seemingly obvious point that I had never consciously recognized: doctors are beacons of hope, and at any given time need to be at once realistic with yet supportive of the patient. That means portraying yourself as supremely confident in the face of this adversity, and it means that you have to have a game plan ready for the patient to follow treatment-wise, because they will cling onto what you say with their life.

Volunteering:

Alzheimer’s Association: Summer 2017 + Autumn 2018 + Spring 2019 (106 + 12 + 2 + 3 +3) (as of 4/9/19)

Rardin Free Clinic: 72 hours (as of 4/9/19)

James Cancer Hospital: 110 hours (as of 4/18/19)

OSU Disabilities Services Notetaker: 64 hours (2/8/19)

Total: 372 hours

Main List:

  • The data that a large organization has to deal with is staggering. 40,000 entries and manual editing is a nightmare. More importantly, optimization is not just a want in this sector, it’s a NEED. I’ve researched all about the VA’s technological despair during my debate days, but seeing a situation like it and working in it was stunning and quite unexpected.
  • The planning that goes behind an event, such as a walk, takes a tremendous amount of labor that not many people see, whether that be putting together folders, folding brochures, and transporting large quantities of walk materials like crates of supplies, large banners, and unwieldy stands.
  • Most people are unwilling to answer phone calls, or if they do, stay on them for an extended period of time regardless of the call’s purpose. Generally, phone calling is a highly inefficient way of reaching people, and a more efficient route needs to be discovered before the phone calls turn into a time sink that drain people.
  • DO NOT EXPECT EVERYONE to follow your advice, or be diligent about what they are supposed to do, whether this be fulfilling a commitment made, or simply listening to the best mode of action. People are stubborn.
  • Non-profits can be as competitive as your greedy Silicon Valley start-up.

 What I learned and dealt with emotionally:

I was simply performing a routine set of calls to ensure that donors and sponsors were keen on their commitment to support the walk, when I ran into a lady with a unique problem. Both of her parents suffered from some stage of Alzheimer’s, and she and her sister dedicated an immense amount of time to the cause. That wasn’t the struggle. The struggle was when she mentioned that an “undercover” cop showed up at one of her yard sales to raise money for the cause, and began questioning her integrity. This was clearly the man’s fault, yet I was being rebuked for that reason. After over half an hour of abuse, I finally managed to help calm the lady down, because I understood her concern. I then redirected her issues towards my superiors, who successfully dealt with the issue.

While I never impress myself because I have extremely high expectations, I couldn’t help but feel a little bit more mature, as I had followed my father’s advice and stayed calm in the face of so much anger. While I didn’t learn anything distinctly new here, it surely reinforced the concepts I had been taught, and allowed me to grow as a human.