Something that I have come to learn after years of practice in medicine and geriatrics is that the WILL TO LIVE is something magical and powerful. And the WILL TO LIVE (or not keep living) is a powerful force that is difficult to scientifically explain. It is something that I have experienced both personally and professionally.

When I was in my fourth year of medical school, my grandmother became suddenly ill. It took a while for the doctor’s to figure out what caused her to have intermittent fevers, but tests finally revealed that she had Hodgkin’s Lymphoma. If there was such a thing as a “good cancer”, I think Hodgkin’s would fall into that category. Unlike other cancers, Hodgkin’s disease is even potentially curable in late stages. My grandmother went through several rounds of chemotherapy and was responding positively to the treatments. Unfortunately, however, she developed an adverse effect from one of the chemotherapeutic agents she had taken. She developed end stage lung disease as a result and had to be hospitalized. She was ultimately intubated (on a breathing machine) and our family was taking nightly shifts with her in the ICU so that she would never be alone. She was a caregiver for my grandfather, who was 89 years old at that time. They had been married for 58 years and she knew that he needed her. I believe that it was her will to live that kept her alive on the ventilator when she should’ve passed many days earlier. On the day before her death, I remember taking her hand in mine and instead of telling her to fight (like we had been doing the last few weeks), I whispered to her that it was okay for her to stop fighting. I assured her that everything would be okay and promised her that we would take care of our grandfather. It might have been coincidence that she passed away later that evening, but I honestly don’t think so. I think it was her will to live that kept her from dying several days earlier when she had suffered cardiac arrest in the ICU….and her will to finally let go that allowed her passing. My grandfather died in his sleep in their home 30 days after my grandmother’s death. While she willed herself to live longer than expected, he had truly lost his will to live.

A few years ago, I was taking care of an elderly man who had 2 sons. He lived with his eldelst son, who was at his bedside for most of the 2 months that I was caring for him. He was diagnosed with late stage pancreatic cancer and had been transferred to the nursing home for end of life care. For the first several weeks, the patient was alert and communicative. I was working to help treat his pain and discomfort, which we were ultimately able to control. He spent the last 20 days of his life lying in bed with his eyes closed. He was non-communicative and did not eat or drink. I usually tell patients that most people die after 3-7 days of no fluid intake. However this was not the case for this particular patient. While the patient lay in bed with his eyes closed in what we would call a “coma”, his eldest son was constantly counting down the days for him until his youngest son’s arrival. Although he was in contact with his youngest son, who was overseas, he had not seen him in over 6 years. He waited….and the moment of his death with both sons at his bedside was one of the most beautiful moments I have ever witnessed. Upon the arrival of his youngest son, my patient opened his eyes (they had not been open for almost 3 weeks), he smiled, squeezed his son’s hand and took his last breath. His will to live kept him alive until the arrival of his youngest son.

The simple WILL TO LIVE cannot ward off cancer or fight a bacterial infection. But it is definitely necessary in some cases to heal and overcome illness. It can also keep someone alive longer than can be medically explained. It is a beautiful force that is within each and every one of us.

Designating someone to be your decision maker when you are incapacitated is a very important decision. In a previous post, I discussed how it is important to designate a durable power of attorney (DPOA). You might think that the person you are closest to should be the obvious choice. For example, a spouse or child or sibling. Most of the time, this is the case, but you do need to be thoughtful about whom you designate. The person you choose should know you WELL. They should also be able to separate their own desires and needs from what they should know would be your wishes. You cannot ever assume that your DPOA knows where you stand in regards to issues of resuscitation, feeding tubes and other unexpected medical decisions that may need to be made. I have seen too many times where your designated DPOA acts as “they (themselves) would want to be treated” and not necessarily how you yourself would’ve chosen to be treated.

A good way to try and make the best decision for your loved one if you have never had a “formal discussion” with them is to imagine if your loved one were standing next to you and were able to see himself/herself lying there right now…ask yourself what would he/she tell you to do for them? I have heard a range of responses. : “That stubborn bastard would want me to do everything possible to keep him alive……even though that’s not what I would want”. Other responses are a bit more heartfelt: ” She would absolutely tell me that if God were ready to receive her that she is ready to go…she didn’t want to be a burden to me…but I always tell her she is not”. In both of these cases we try and project what we would want for our loved ones….when the answer is right before our eyes. What would THE PATIENT, your loved one, want? A DPOA should act as the person would for themselves. Push away any guilt, fear, anger or love…and do your job. Be the voice of the patient who is lying in bed and can’t speak for himself./herself.

A funny story comes to mind. I was meeting with a couple who had been married for over 50 years. They had designated each other as DPOA but they never really talked about what each other’s wishes would be in case of an unexpected health crisis. The wife was my patient. She had recently been hospitalized and had been on a ventilator (breathing machine) for almost a month. When she was taken off the ventilator, rather than being relieved and thankful for recovering from her pneumonia….she was angry with her husband. She had never wanted to be connected to a ventilator and she made it clear to me (with her husband present), that should her lungs fail again…that she would not want to be intubated. She wanted a Do Not Resuscitate (DNR) order placed on her chart. He was so surprised because he thought that she would be grateful that he had made the decision to “save her life”. I sat next to the couple as they discussed their wishes. The husband’s wishes were quite the opposite to his wife’s. He didn’t want her to “pull the plug” for at least 6 months! His wife laughed and said, “wow, if we didn’t have this discussion I would’ve given you 2 weeks!”. They made light of a very serious situation …but this interaction highlights how people’s views, even those that we are closest to, may be quite different from what we expect.

I was treating another patient who suffered from multiple strokes. She was essentially bedbound with a feeding tube when I had my discussion about “code status” with her. We had a long talk about what she considers a “good quality of life”. And she looked me in the eye and said…as long as I have my vision and can see the sunset, I will be happy and I would want you and any doctor to do whatever it takes to keep me alive.

A sunset for one patient, ice cream for another and just hearing a loved one’s voice for yet another. Everyone has different things that they value; different things that they would want to continue living for. Do you know how you would define “ good quality of life”? Once you figure it out, it is very important to share that with whomever you have designated as your power of attorney.

We’ve all seen it before on TV: a victim falls to the ground and a Good Samaritan comes to the rescue, begins CPR and revives the person. CPR stands for Cardiopulmonary Resuscitation. It is a method of trying to simulate and restore circulation to a person who is unresponsive and without a pulse. It can be a highly effective means to save someone’s life, however it does not have the magical quality that is often conveyed on the big screen. Unfortunately, real life does not imitate television.

Success rates of CPR are based on a number of different variables including:

-The cause of the cardiac or respiratory arrest

-Age and health of the victim

-Time elapsed between arrest and initiation of CPR

-Technique used by person performing CPR

-Location of patient when arrest occurs (i.e. in hospital or out of hospital)

In June 1996, The New England Journal of Medicine published a study about success rates of CPR portrayed on television medical shows such as “ER”, “Chicago Hope” and “Rescue 911”. According to the television shows, CPR is successful about 75% of the time. This is significantly higher than “real-life” CPR success rates published from other studies.

Without the use of automatic defibrillation, survival rates of CPR are as follows:

• 2-30% when outside of the hospital
• 6-15% for hospitalized patients
• Less than 5% for elderly patients with chronic medical problems

Often those who are hospitalized are faced with having to make the decision whether they would want to be “resuscitated or not”. Many people feel that if they choose “do not resuscitate (DNR)” it means that the doctors will not try their best to help them. This is a myth. Do Not Resuscitate does not mean Do Not Treat. Patients who choose to be DNR will still be treated for such things are pneumonia, cancer, choking, heart attacks and even broken bones. They will, however, be allowed to die naturally should their heart stop beating.

Many of us turn to TV and the big screen in order to escape reality. By exaggerating true outcomes, Hollywood does its job and often allows us a reprieve from current life stresses. Sometimes, however, sugarcoating outcomes leads to unrealistic expectations when dealing with a loved one’s illness or injury. Making decisions based on real facts versus television statistics will better serve us all when confronted with unfortunate events and illnesses.

I recently lost my father unexpectedly from sudden cardiac arrest. The journey that I was thrust into with my mom, brother and immediate family has given me a deeper and broader perspective of life, its meaning and its fragility. As a geriatrician, death is something that I deal with on a weekly (if not daily) basis. I have conversations with people about death and dying. I fill out death certificates. I perform CPR on patients. I pronounce people dead. What I haven’t ever been a part of though (until recently), is sitting in a cold funeral home with an uncompassionate funeral director picking out a casket for my own father.

I have always treated my patients with the compassion and respect that I would give my own parents. I answer any questions they have and treat their adult children with the same respect that I would hope to be treated with.   I make myself available and try not to leave any rock unturned. After losing my father, I realize how important kindness and compassion during a difficult time really is.

What I am going to be sharing today is not a prescription for life written by an M.D, but merely some thoughts on life from a grieving daughter . Things that my father’s sudden death have taught me:

1. Spend as much time as we can with those we care about.

My parents fortunately have always lived a very full and independent life.   Unfortunately, however, they do not live in the same state as me. We make an effort to see each other often…which usually turns out to be every 3 months or so. I feel blessed to have spent a week with my father about 3 weeks before he died. He and my mother came out to visit in September “just because”. We were able to celebrate my mother’s 67^th birthday before they headed off to Vegas (one of their favorite places to go). During this week, we didn’t do anything special, but my kids got to spend time with their grandparents and I got to spend some quality time with both of my parents. I will forever remember and appreciate the time I spent with my dad during their visit.

I also realize that “time” spent together does not have to mean physical time spent together. Time spent talking can be just as meaningful, and in my case, it definitely was. I always complain about my long commute to and from work, however, if it were not for my commute, I would not have had the time that I did with my dad on the phone only 2 days before his death. I will forever cherish that 40-minute conversation that we had full of laughs, advice and everything in between.

2. Show those that we care about just how much we do care about them while we can.

My dad did not show love and compassion with words of affection or hugs or kisses. Instead, he would wash dishes incessantly and accommodate any request that was made. He would fix things around the house, take out the trash and take his grandson to Disney World for his 10^th birthday. Initially after my dad’s death, I felt guilt about not telling him more often how much I loved him. I realized, though, that I knew just how much my dad loved me through his actions without him having to tell me (with words). I accept now that he knew that I loved him as well even without me telling him…..I have no regrets.

3. We need to recognize and embrace the positive qualities that each of us possesses.

It wasn’t until I was writing my dad’s eulogy that I recognized one of his most positive and unique qualities: he never complained. My dad was the most devoted and hard working father you could imagine. He did not show his love through words or hugs or kisses, but instead, his love was shown with his devotion and constant attention to our needs. He packed our school lunches everyday. He tirelessly drove my brother and me all around town (to school, music lessons, sporting events, etc). I have no memory of him ever complaining or even seeming annoyed about any of this. I think I would have appreciated my dad even more had I realized these qualities while he was still alive. My mother would always recite to me Serenity Prayer I would read it….but did not “get it” like my mom obviously did. I do now.

4. Offer your love and support to those who have suffered a loss.

I have sent out some sympathy cards in the past, but didn’t think it made much difference. What I soon realized after my father’s death is that every text message, every card, every bit of food or flower arrangement, every offer to help and every telephone call really does matter. As humans, we have the ability to feel emotions and communicate these emotions with words and actions. We should use them and use them wisely.

What I learned with my father’s death is not something that I learned in medical school. Losing my father has given me an even more compassionate view of life. As a physician, I can diagnose. I can prescribe medications. I can even prolong life to some extent. I realize though, that I cannot take away the pain of losing someone. I do hope that I can offer reassurance to each and every one of you to know that we can all make a difference in the lives of those with whom we are lucky enough to encounter. We can offer love, kindness, and respect to each other. We can love like there will be no tomorrow…because there just might not be. Live a life with no regrets!