How to die — a physician's last lesson

Sureshini Sanders

My father was a big man, in more ways than one! He was my mentor, guide and friend, on a personal and professional level. The last lesson he taught me, was how to die. There has been much in the BMJ and press lately on death, care of the elderly, concerns about patient choice and dignity. My father chose a low tech, minimal intervention, home death. He and death had a long relationship. He knew death intimately, as a retired geriatrician and because he had cheated death already.

He had a cerebral haemorrhage 13 years before, when he was working flat out as a consultant. He had a massive insult to his brain and his case notes recorded ‘no CPR’, with our agreement. On that occasion he won the battle and walked out of hospital 8 weeks later to spar another day. Life was not easy after this event but he and my mother managed independently, travelled abroad extensively and saw five grandchildren, who were a delight to him.

In December last year death visited him again. He developed a chest infection that seemed to respond to antibiotics but then returned with right sided pleuritic pain. He conceded to further investigation. Our local chest physician was wonderful and knowing his mobility issues organised everything on 1 day and told us he had a 5 cm lesion in his right apex, extensive mediastinal, adrenal and possibly liver involvement. She treated him as a colleague/patient and discussed the options available, which were very limited, only palliative and, at best, would extend his life by a few weeks.

My father in discussion with the doctor decided not to have a biopsy and, another painful trip to hospital. He felt it would be academic, as he saw no benefit in going for palliative treatment. He told us all to return to work as normal, as he intended to continue with his daily routine. He informed only his siblings, and he wanted as little fuss as possible. He was a man of faith and believed quite simply that his time had come. Now death would have him but unlike everyone around, he shed no tears. He gave my mother a quiet time to adjust to the news.

A few weeks later my father lost his vision and casually informed us that he probably now had cerebral spread. We were not to call his GP out unnecessarily, as there would be little she could do, but he requested a prescription of dexamethasone as a last attempt to regain his vision. At this point I became distressed at work and my kind colleagues advised me to stop.

We had 2 precious weeks and talked non-stop about how it would be, this dying. How he would like it to be. He spoke to my mother on how to manage without him, and organised his finances. He got me to purchase his burial plot. During this time he managed to partake in his grandsons' birthdays and Mother's day celebrations. He enjoyed what life he had left with his family and did not wait upon death. A fortnight later he went off his feet. My mother, sister and I could not lift him, so we called our brother, who then became the human hoist. He would put dad in a wheelchair and we carried on as before. We were all five together now, as we used to be. It was a bittersweet time. Our father kept to his daily routine in spite of increasing pain, breathlessness and lethargy.

The GP visited weekly and gave dad morphine. He tried it once but became constipated and less able to assist my brother with transfer. He decided to do without and instead managed with a combination of paracetamol and ibuprofen. I must admit that had it been me, I would have consumed the morphine by the bellyful but I suspected that he had a plan. He wanted at all times to be in charge of himself and with three children, all doctors, had a fear of what great ideas we would cook up between us!

Next his renal output diminished and he developed gout. He was not keen on further medication for fear of side effects and suggested elevation and ice, a good old-fashioned remedy. He developed hip and shoulder pain, so we massaged him. My siblings and I procured various continence aids, which lay concealed in the boot of my car, as he would surely sooner or later need these, but he didn't. His appetite was poor and he declined build-up drinks, so I learnt to make bread and butter pudding, caramel pudding and all the egg and milk-rich treats my grandmother made and that he loved as a boy. I had to seriously brush up on my wartime cookery skills.

One day he told me he needed his bed. It was only 7 pm and he was veering off his schedule. He insisted, however, that I get my brother and then we knew that the end was in sight. After saying goodnight to us all, he finally said he would take his morphine. It was to have a profound impact on one so debilitated, without previous exposure, and within 36 hours he was gone.

The Scotsman had 20 obituaries that week. Only two of these deaths were at home and both were doctors. I think my father knew how to die. He faced death, as he faced all issues in life, full on. No doubt his own medical knowledge helped him and we were lucky, in that all the doctors who attended him were so mindful of his wishes. He had his low tec, minimal intervention, no counselling, few drugs death. In some ways he was a simple man and he had a simple death. Sadly so few of our patients do so. Perhaps we need to encourage them more. Fight for life by all means but when the end comes, precious time should not be wasted on would-be cures, holy grails, net searches and trips to hospital! Death is a certainty in every patient's life and we should be helping them face this final event with dignity.

My father taught me well. He cheated death again for he had no fear.