If you are a fan of shoot-em-up movies, this is a familiar theme. A conflicted, macho warrior, say Nicolas Cage, in a steamy jungle, surrounded by faceless, merciless enemies, carries on a futile fight. Soon, all of his men lie dead. Then, through the rest of the film, this flawed man, in eternal pain, haunted by visions of friends and wasted lives, says, again and again, “But, I was just following orders.” Our hero finds peace only in the grave.
War is about orders. Men and women do things that no sane, moral or compassionate person would choose. Destroy, kill and sacrifice, for a greater cause. Treasure, land, family, truth, god, justice. A pure mission reduced to a set of unalterable, unquestionable, resolute instructions. Orders. Do and die.
I met Donald in the emergency room; whisked in, sirens blaring, by rescue squad. He was confused, gasping, fluid gurgling in his throat, a pressurized oxygen mask on his face, arms flailing as he tried to pull in air. His skin, pale, moist and cold, hung loose over wasted arms and legs. Don’s skin was covered with the giant, almost continuous bruises that doctors call purpura, a result of malnutrition, countless intravenous sticks, and chronic use of blood thinners to combat recurrent clots. He had been a very sick man, for a long time.
Don was a patient of an oncologist at another hospital, where he was treated for lung cancer. He had undergone several surgeries, chest radiation, brain cyberknife and months of chemotherapy. The aggressive therapies did not stop or slow the lethal disease. It was obvious that Don was dying and he was dying now.
Away from Don’s agony, I sat down with his wife, Rose, their son, and daughter at her side. I gently, slowly, explained his terminal condition. This was how lung cancer patients die. His lungs were filling with mucous, infection and blood, caused by progressing cancer. Soon, he would stop breathing. Don could not be saved; he would not leave the hospital. It was critical that we give Don peace. Sedation and morphine. The dignity of a gentle end.
Rose listened carefully. She sat quietly sobbing, hands shaking, tears running down her cheeks. Her daughter put an arm around Rose’s shoulders, I held her hand in mine. She thought for a few moments. Then, looking down at the floor, Rose said, “Put him on a machine. Pound on his chest, if you must.”
I was shocked. This was as clear of an end-of-life, keep the patient comfortable moment, as one ever sees in cancer medicine. It took me a moment to recover. Stubbornly, I repeated my diagnosis and prognosis. Machine or no machine, CPR or not, Don would absolutely die during this hospitalization.
Rose listened. She nodded. Then, her hands rising to cover her eyes, Rose said. “Put him on a machine. Don said, he made me promise, that whatever happened, no matter what, he wanted everything done.” Don had given orders.
For Don, his war on cancer came down to futile hope, expressed as a cruel command. He had ordered Rose, his family, to fight an impossible battle. Push beyond merciful reality. They would suffer and so would he.
For eleven days, in the intensive care unit, Don lay connected to a respirator machine. He never became focused or alert. He thrashed and pulled at IVs and yanked at the tube down his throat. After the first day or so, we gave up trying to keep him awake. We paralyzed Don and knocked him out with intravenous drugs. Don was unconscious for the rest of his life.
For the first couple of days his family maintained a vigil. However, it was painful to listen to the gasps of the machine, watch the fluids drip in and run out, see him, occasionally, wince. Then, they came only during the day. In his last hours, they did not visit at all.
Rose called Don’s nurse daily, at 7:00am and 4:00pm, for the report. I called his family each morning, reassuring them that in a medical coma, Don was not in pain. I presume they went woodenly about their lives, somewhere else. The nurses tended the machine, the labs tracked the failure of his body, and the monitor’s beep announced the weakening of a dying heart.
When he arrested at 2:14am, we called a code. The team pressed on his chest, broke a few ribs, stuck in long needles, poured in fluids, and injected medications. Shocked him twice… three times. They called it at 2:38am. Don was dead. He was left, for a while, alone in the technological silence of a night ICU. When his family said they were not coming in, a gurney took the cooling body to the morgue.
No one wants to die. Nonetheless, to be human is to be mortal. We forget, sometimes, that the struggle is not against death, a foe we can never defeat, but for life. It is one thing to whisper, “Do everything you can to help me live, while I can,” and another to command, “Do everything, even if it destroys me and you.”