Self-expression is rarely easy for patients because words often cannot articulate how patients feel inside. Children are often asked to draw pictures in order for psychologists to gain insight into perceptions surrounding particular life experiences. Paul, a 57-year-old patient with a provocative and morbid sense of humor, stunned the ER staff with a tattoo on his left forearm depicting how he felt on the day he had a heart attack (05/08/2004). This was a day marked in infamy and a declarative moment of Paul’s legacy: My heart’s been stabbed, but my spirit remains defiant.
While laughing in the face of danger and standing before the grim reaper, Paul’s mockery of death was lighthearted and balanced. His ability to wrap his head around having a heart attack with a twisted sense of humor was actually an effective coping mechanism that offered an inspiring message. Others can easily identify and become uplifted by Paul’s apparent vulnerability and survivability. While possibly taunting the grim reaper, Paul clearly allowed this satanic force to get under his skin and permeate his being.
Male ego prompts the slogan, Never let them see you sweat. Each of us is threatened by our own mortality and a predictable sense of betrayal by our bodies. Naturally, one of the major organs is destined to fail and ultimately be the cause of our own death. As unsettling as this may seem, we still have the ability to maintain composure. We can make the best of a bad situation while not allowing devastation to get the better of us. The real crime of passion, stirred by betrayal, is allowing anger to become passive aggressive and self-sabotaging.
While dissecting and digesting this tattoo, Paul mentioned that his cardiologist was particularly drawn to the gross anatomy and attention to detail that the artist gave to the image of the heart. A heart attack can be both a real life situation and a spiritual awakening. In Anatomy of the Spirit: The Seven Stages of Power and Healing, Caroline Myss, Ph.D. brilliantly describes how the seven sacred chakras are integral to understanding the mind-body relationship. The more mindful and in tune we are with our bodies, the more we hear our hearts speak. This “intuition” releases the tension inherent to living and unleashes the power to heal.
Tattoos might be seen as a form of self-mutilation – self-mutilation understood as an intentional release of psychological stress. While some people often feel that self-mutilation represents a danger to self, others find mortification of the flesh sanctifying. Through wearing his wounded heart on his sleeve, similar to the stigmata, Paul proclaimed himself to be the sacrificial lamb representing all who are at the mercy of the grim reaper. Once the grim reaper ultimately removes the stake from Paul’s heart, his life will end. In the meantime, he has continued to live his life fully through the gift of self-expression and by leaving a lasting impression on others through his spiritual revelation.
When Letting Go Becomes a Luxury
Silva was sitting in a wheelchair next to her husband, John, who had been admitted to the emergency department due to chest pain and dementia. Silva herself was recovering from hip surgery which had necessitated their downsizing and moving to assisted living just five days prior. While John resided in the memory care unit, Silva qualified for the independent living quarters. The stress was tearing the two of them apart and no less than ten family members were at bedside, caught in the middle of this heartbreaking upheaval.
Despite John’s tears and agitated state, he seemed to be destined for a better place. He had a weak heart and a history of a previous stroke and PTSD, yet he maintained the demeanor of a soldier when called to attention by the ED staff. Unbeknownst to Silva, she had become the primary focus of John’s treatment plan. John did not wish for or require hospitalization; he needed palliative care. Silva needed to be able to let go of the metaphorical handle that was preventing others from entering her domain.
The gift of receiving palliative care is that it is less about letting go and more about allowing others in. As a physician, I am often called to woo patients and entice them with the latest, greatest care plan. At my work station, Silva and her son listened intently to my sales pitch regarding palliative care. Building upon the premise that assisted-living is where the living is easy, I explained palliative care bridges advance care and end-of-life transition. It often allows patients the luxury of staying home after they let go of the need to be hospitalized.
Silvia had the choice of doing this the easy way or the hard way. The hard way involved admitting and schlepping John through the tumultuous maze of the hospital, ultimately having him admitted to a skilled-nursing facility. This would leave John even more separated from Silvia. The luxurious way was to have John maintain his footing and dignity through remaining as nearly and dearly as possible next to Silvia. When couples cannot bear to be apart, they suffer undo stress in the long run. How to make the best of a difficult situation is realizing upfront what is important to hold on to and what to let go of.
A recent Fox News article commended the bravery of 14-year-old girl named Jerika Bolen on her decision to forego living with spinal muscular atrophy and withdraw ventilator support at the end of summer. Bolen’s physician, a pediatric palliative care practitioner, stated that the standard of care for patients with spinal muscular atrophy is to provide comfort measures. Reportedly, Bolen expressed that she was “super happy” and no longer needed to think about anything bad.
Similar to Jerika, Silva had to let go of the need to prolong John’s life in order to grant him peace of mind and offer less heartache for everyone involved. A palliative nurse was consulted in the ED and arrangements were made for John to return home. John seemed to be all smiles as I bid farewell. We mutually thanked each other for our career service and the family expressed gratitude. The state of great comfort – luxury – is the quintessential wish to die for and the appropriate accommodation for those near the end of life.
John was an 88-year-old ranch owner who struck gold when he sold his homestead in Wyoming. His “golden years” in Arizona were spent struggling with back pain and caring for his 80-year-old niece with dementia. He ran out of pain medication and presented to the ER for another “handout” of hydrocodone. He admitted that life was taking its toll and he was beside himself from aging. Was it time to stop doing for others and start allowing others to do for him? Might it be time to disavow “survival of the fittest” for the chance to ease his suffering?
It seemed survival of the fittest had cost him dearly. He proudly told the physician that he had $300,000 in the bank and told the nurse that he had sold his ranch for 10 million. He had recently spent $15,000 for both himself and his niece to have a get-well-quick remedy of electromagnetic alignment in a Mexican clinic. In addition, he was not sure if the “male booster” that he was receiving monthly through the mail was doing him any good at his stage of life. Nevertheless, it was being sent by the powers that be for free. The physician suggested that he check his monthly credit card statement for this “free” product.
Survival of the fittest might default to having money to burn, expending large amounts of treasure and energy on the losing prospect of anti-aging. Physicians need to continually remind patients and family members that it is not necessary to prove anything after the age of 85 – survival of the fittest does not apply and is not grounds for advocacy. The “golden years” are meant to be as carefree as the school-aged years. These age groups similarly assume some responsibility, but do require a guardian. Care provided to persons near the beginning and end of life needs to be mindful, conservative and less damaging over the long run.
Survival of the fittest is reflected in the headline article from Medscape – Letting Go: No Reduction in Aggressive Care for Advanced Cancer. Ronald Chen, MD from the University of North Carolina at Chapel Hill conducted a study that involved 28,371 patients with metastatic cancer who died from 2007 to 2014. His findings indicated, “Despite being ‘widely recognized to be harmful to patients and their families,’ aggressive care is still administered to the majority (75%) of [these] patients.’ Moreover, the article states, “This included about two-thirds of patients who were admitted to the hospital or the emergency room in the last 30 days.”
While some may question both the definition of advanced cancer and whether age is a state of mind, it might be best to define advanced cancer as occurring in people over the age of 85 that cannot be conservatively managed as an outpatient. Naturally, survival of the fittest is called into question anytime these patients arrive in the ED. The certain reality is that these patients are no longer surviving and are in fact dying. How physicians treat patients at this juncture is to either restore confidence in their being fit for graduation or advocate indignation through their being fit to be tied in an ICU bed.