You havent recognized them in years, you havent spoken a coherent word in months, and even if for some reason your brain chose this moment to recover lucidity youre on enough morphine to be well inside the borders of la-la-land. A lot of families, faced with the prospect of missing work and school to sit by whats basically a living corpse day in and day out for weeks just to watch it turn into a non-living corpse, politely decline. I absolutely 100 cannot blame them. There is a national dark volunteer program called no one dies Alone. Nice people from the community go into hospitals to spend time with dying people who dont have anyone else there for them. It makes me happy that this program exists. Nevertheless, this is the way many of my patients die. Old, limbless, bedridden, ulcerated, in a puddle of waste, gasping for breath, loopy on morphine, hopelessly demented, in a sterile hospital room with someone from a volunteer program who just met them sitting by their bed.
And you will die, but not quickly. It takes time for the heart to give up, for the lungs to fill with water and stop breathing, for the toxic wastes to build. It is generally considered wise for the patient to be on epic doses of morphine throughout the process, both to spare them the inevitable pain as their disease takes their course and to spare their family from having to watch them. Not that they always. It can take anywhere from a day to several weeks for someone to die. Sometimes your family wants to wait at the bedside for a week. But a lot of the time they have work and things. Maybe they live thousands of miles away.
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Dont those stupid cryonicists realize all that money could be spent on charity, instead of chasing after fantastically unlikely chances?). Robin Hanson sometimes writes about how health care the is a form of signaling, trying to spend money to show you care about someone else. I think hes wrong in the general case most people pay their own health insurance but I think hes spot on in the case of families caring for their elderly relatives. The hospital lawyer mentioned during orientation that it never fails that the family members who live in the area and have spent lots of time with their mother/father/grandparent over the past few years are willing to let them writing go, but someone from 2000 miles away. Your doctors will nod their heads and tell your family they respect their wishes. It will be a lie. Oh, sure, they will carry out the familys wishes, in terms of continuing to provide the care.
In the cafeteria at lunch, they will despite medical confidentiality laws that totally prohibit this compare stories of the most ridiculous families. I have a blind 90 year old patient with stage 4 lung cancer with brain mets and no kidney function, and the family is demanding, i enroll her in a clinical trial from Sri lanka. I have a patient who cant walk or speak whos breathing from a ventilator and has anoxic brain injury, and the family is insisting I try to get him a liver transplant. Every day, your doctors will meet with your family another time, and eventually, as your condition worsens and your family has more time to be hit on the head with a big club marked reality, they will start to relent. Finally, they will allow your doctors to take you off of the machines, and you will be transferred to palliative care, whose job I do not envy even though every single palliative care doctor I have ever met is relentlessly cheerful and upbeat and this.
My patients who have the sorts of issues I mentioned in the last paragraph are generally alert and oriented. They dont remember their own names, they dont know where they are or what theyre doing there, and they think its the 1930s or the 1950s or dont even have a concept of years at all. When youre alert and oriented x0, the world becomes this terrifying place where you are stuck in some kind of bed and cant move and people are sticking you with very large needles and forcing tubes down your throat and you have no idea why. So of course you start screaming and trying to attack people and trying to pull the tubes and iv lines out. Every morning when I come in to work i have to check the nurses notes for what happened the previous night, and every morning a couple of my patients have tried to pull all of their tubes and lines out.
If its especially bad they try to attack the staff, and although the extremely elderly are really bad at attacking people this is nevertheless Unacceptable behavior and they have to be restrained ie tied down to the bed. A presumably more humane alternative sometimes used instead or in addition is to just drug you up on all of those old-timey psychiatric medications that actual psychiatrists dont use anymore because of their bad reputation. After a while of this, your doctors will call a meeting with your family and very gingerly raise the possibility of going to comfort care only, which means they disconnect the machines and stop the treatments and put you on painkillers so that you die. Your family will start yelling at the doctors, asking how the hell these quacks were ever allowed to practice when for Gods sake theyre trying to kill off Grandma just so they can avoid doing a tiny bit of work. They will demand the doctors find some kind of complicated surgery that will fix all your problems, add on new pills to the thirteen youre already being force-fed every day, call in the most expensive consultants from Europe, figure out some extraordinary effort that can. (then these people will go home and log onto the Internet and yell at cryonics advocates for being selfish for wanting to live longer.
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You will become completely dependent on nurse assistants to intermittently shift your position to avoid pressure ulcers. When they inevitably slip up, your skin develops huge incurable sores that can sometimes erode all the way to the bone, and which are perpetually infected with foul-smelling bacteria. Your limbs will become practically vestigial organs, like the appendix, and when your vascular disease gets too bad, one or more will be amputated, sacrifices to save the host. Urinary and fecal continence disappear somewhere in the process, so youre either connected to catheters or else spend a while every day lying in a puddle of your own wastes until the nurses can help you out. The digestive system isnt too happy either by this point, so you can either have a tube plugged directly into your stomach or just skip the middleman and have an iv line feeding nutrients into your bloodstream. Somewhere in the process your mind very quietly and without fanfare gives up the ghost. It starts with forgetting a couple of little things, and progresses until you have no idea whats going on ever. In medical jargon, healthy people are alert and oriented x 3, which means oriented to person (you mattress know your name oriented to time (you know what day/month/year it is and oriented to place (you know youre in a hospital).
The copd means you homework have to breathe from an oxygen tank you carry around wherever you. The pvd will prevent you from walking more than a few feet at a time. The esrd will require three hours dialysis in a hospital or outpatient dialysis center three times a week. The iddm will require insulin shots after every meal. Not fun, but hardly inconsistent with a life worth living. Eventually these will add up beyond your ability to manage them on your own, and you will be sent off to a nursing home. This will seem like a reasonable enough idea, and sometimes it goes well. Other times it gives you freedom to develop a completely new set of morbidities totally unconstrained by what a person in any other situation could possibly be expected to survive. You will become bedridden, unable to walk or even to turn yourself over.
When you were young, you would go to institutions and gradually gather letters after your name: ba, md, phD. Now that you are old, you do the same thing, but they are different institutions and different letters. Your doctors will introduce you to their colleagues as Mary Smith, copd, pvd, esrd, iddm. With each set of letters comes another decrease in quality of life. At first these sacrifices will be minor.
And your last words will probably be something like mmmrrrgggg graaaaaaaaaaahaaack! I guess i always pictured dying as unless you got hit by a truck or something a bittersweet and strangely beautiful process. Youd grow older and weaker and gradually get some disease and feel your time was upon you. Youd be in a nice big bed at home with all your friends and family gathered around. Youd gradually feel the darkness closing. Youd tell them all how much you loved them, there would be tears, you would say something witty or pious or defiant, and then you would close your eyes and drift away into a dreamless sleep. And I think this happens sometimes. For all i know, maybe gpa it happens quite a lot. If it does, i never see these people.
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Trigger warning: death, pain, suffering, sadness. Some people, having completed the traditional forms of empty speculation What do you want to be when you grow up?, If you could bang any celebrity who would it be? turn to What will you say as your last words? Sounds like a valid question. You can go out with a wisecrack, like oscar Wilde (Either this wallpaper goes or I do). Or with piety and humility, like jesus (Into thy hands, o father, i commend my spirit.) Or burning with defiance, like karl Marx (Last words thank are for fools who havent said enough.). Well, this is an atheist/skeptic blog, so let me do my job of puncturing all your pleasant dreams. Youll probably never become an astronaut. Youre not going to bang Emma watson.