CENTRAL  SOUTH  DAKOTA  MEDICAL NEWS
THE CLINICAL VIEW
By: Phillip E. Hoffsten, M.D.
10/12/2000

The Drive to Survive

Easop was a Greek slave who was said to have lived from 620 to 560 b.c. He is credited with writing a large number of fables which have been collected into a book many of us are familiar with entitled, Easop's Fables.  If you have not read the book, certainly many of the fables themselves have been heard such as the story of "The Lion and the Mouse" or "The Fox and the Grapes". These stories have excellent messages and lessons for all of us although they are often told as children's stories.

One of the less well-known fables is entitled, "The Old Man and Death".  It relates the story of an old man traveling a great distance with a heavy bundle of sticks. He grows very weary developing fatigue and all of the pain that comes from intolerable fatigue. The old man drops the sticks to the ground. He then "calls upon death to deliver him from his most miserable existence." As the fable goes, death comes promptly to the old man's side and asks him what he desires. Face to face with death, the old man states, "Please, good sir, do me a favor and help me lift my burden again." The moral of the story offered by Easop is, "It is one thing to call for death and another to see him coming."

To me, the story is an illustration of something health care professionals experience everyday. Specifically, we see that human beings are endowed with an intense "drive to survive." It seems that every reflex, every instinct, every motive that humans are endowed with are directed to help survival and continue to live. As the fable above illustrates, this drive persists through adversity we all hope we will never have to face.

Dealing with loss of life is a very individual experience. I am reminded of the person who told me he would like to pass away in his sleep peacefully like his grandfather who fell asleep while driving his car; he did not want to die yelling and screaming like the other four people riding with his grandfather. Faced with irreversible disease processes some individuals are able to accept their fate with a certain calm and peace. Other individuals struggle mightily against clearly insurmountable disease processes sometimes encountering avoidable misery, pain and suffering prior to their expiration.

The message of this column has to do with steps that can be taken to make an unavoidable death easier for the person dying and for their family. First, if an individual receives information from a health care provider indicating that a mortal situation is present, second opinions are frequently sought. I certainly advocate this. On the issue that is certainly the most important in your whole life, confirming and being sure of a diagnosis is critical.  Alternatives for treatment should be carefully and completely considered. If there are any doubts or questions, second and even third opinions should be sought.

The second piece of advice has to do with planning once a diagnosis and predictable future is established. Family members and the person with  the illness need to communicate regarding the desires of each. Often these desires conflict and family members will "want everything done". It needs to be understood that there is a difference between prolonging a person's life and instead prolonging a person's death.

As an illustration, I recall one of the first patient's that I ever cared for as an intern at VanderBilt Hospital in Nashville, Tennessee. I had just graduated from medical school and was assigned the care of an individual who had a cancer of the bone. He had tumors that had resulted in fractures of both arms and one leg. He was unable to walk and because of the fractures of his arms. he was even unable to feed himself.  I was called at 2:00 in the morning to come see him because he had developed a fever up to 102 degrees Fahrenheit. I dutifully came down, diagnosed his pneumonia and started him on antibiotics to treat the pneumonia. He lived an additional two weeks still with his arms in casts, his leg in traction and unable to move or care for himself with no hope of recovery. While some may argue, I have substantial reservation that I did this man any favor by prolonging his existence for an additional two weeks.

While decisions in the above situation are individual, there needs to be careful and clear communication between family members, the patient and the health care providers. It must always be kept in mind that the health care providers first responsibility is to the patient and fulfilling that individual's expectations as can be done. When a cure is not available, comfort must still be provided in a thoughtful, dignified and respectful way. As in Easop's fable above, the health care provider must help the patient carry his load as effectively as can be done.

The third piece of advice has to do with nutrition. Frequently, patient's in the advanced stages of an illness lose their appetite and food becomes unattractive. I am struck by the number of times when adversarial situations develop between family members and the patient. Family members try to "force" food on the patient that the patient simply does not want and may even find repulsive. Caregivers should provide the nutrition that the patient would like but avoid trying to force nutrition that the patient simply does not want.

Lastly, thoughts about "avoiding addiction to pain medications" needs to be carefully considered. As long as the patient is in pain, they do not have enough pain medication. No matter how much it takes, no matter how often it has to be given, a person with pain in the terminal stages of an illness, has not received an adequate amount of medication. Health care providers should adjust medications and dosages so that pain control is achieved. The concept  of  attaching  social  stigma  to  addiction   from  narcotic  medications  is  misdirected.   The  patient  needs  to  be  provided  with  pain  relief  through  whatever  resources,  narcotic  or  otherwise,  are  available.