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Dealing with Death as Witnesses

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Vincent Valentine, MD
University of Alabama Birmingham
Birmingham, AL, USA

Out of referrals, evaluations, listings and replacement procedures including transplantation and deploying mechanical devices, along with ongoing care and dutiful management comes experience with recovery and death. The thousands of lives we touch regardless will still result in the unavoidable topic of death. It is the pillar that underlies medicine, life, and art. We must turn to the literary arts to add a human dimension of our endeavors in medicine and life. If there is one book that will guide us among many others, it is Intoxicated by My Illness and Other Writings on Life and Death by Anatole Broyard. I believe it is the ultimate must read for all health care providers, especially for the ISHLT. We will benefit from the enlightenment that art can offer. Witnessing death has and will continue to occur, yet do we know what it means to witness death? To what extent is death a reality more for witnesses than it is for the dier?

Faulkner's book As I Lay Dying sets the stage of death. In it, Dr. Peabody says "I can remember how when I was young I believed death to be a phenomenon of the body; now I know it to be merely a function of the mind-and that of the minds of the ones who suffer the bereavement. The nihilists say it is the end; the fundamentalists, the beginning; when in reality it is no more than a single tenant or family moving out of a tenement or a town." Faulkner illustrates this dynamic picture of death as a form of mobility. In conjunction with these mind and body components, great literary works offer various dimensions that allow us to examine death from different perspectives. While an individual cannot suffer death and then be expected to describe it, art is capable of exploring and addressing all view-points of the deceased. We might ask: Who are we in nature's vineyard? How do we experience death, in what ways, and at what distance? Are we the one who dies? Are we the loved one who tends the death of someone? Are we the physician who manages someone's terminal illness? The bystander or the taxpayer, who will pick up the bill? Dying is expensive. In our efforts to resuscitate and support patients through recovery and rebirth, we must bear in mind that our other duty is to recreate or tell the story of a dying patient in effort to maintain their dignity. Also, bear in mind reconstructing the meaning of a person's life as a measure of their death, or the meaning of a person's death as a measure of their life will secure dignity, grace and humanity.

The death story of someone we know is vastly different from that of someone we don't know. Moreover, the death story of someone we know is actually our story. Anatole Broyard's What the Cystoscope Said is a trying, demanding, emotional and brutal story of the death of a son's father. Told from the son's point of view, Broyard prompts readers to question: how do we let go of someone we know?

We all yearn to age gracefully and die with dignity. Further, we are stripped of our entitlements in death or during the act of dying. The son tries to share the workload in hopes to become a man and measure up to his father; a foreman and carpenter. The father's entitlements were his physical strength, pride, and virility; however, Broyard reminds us that patients are yoked by disease as he sets the tone in the opening lines. He opens, "When I saw my father with the horse collar around his neck, I knew immediately." Being yoked, the father experiences a servitude he has never known before (A neck collar prescribed for neck pain from metastatic disease, also note hidden racial overtones). Along with his integrity and authority, his physical strength is now inadequate. While the father is accompanied by his dutiful son, the doctor uncaringly talks with him to get the inside story. "We have a little surpriseā€¦ We want to get the inside story on you, so we're going to give you a cystoscopy. They can be sometimes be unpleasant, but I don't think that will bother an old soldier like you." This is the inside story of dying, or of a son witnessing his father's death. The test is performed and completed, and Broyard offers brilliant metaphoric language, a manifesto of the experience of having undergone cystoscopy.

The son arrives in his dying father's hospital room and registers his own disbelief. The nurse says, "Your father is in there." His quick response, "But my father wasn't in there." The son describes his father "Sprawled on a table, incredibly out of place, lay a plaster Prometheus, middle-aged and decrepit, recently emptied by an eagle, varnished and highly glazed as though still wet...Or perhaps... an eviscerated old rooster, plucked white, his skin shiny with a sweat more painful than blood." Broyard uses sexual and racial overtones to illustrate an impotent cock being plucked white. The son reflects saying, "Whatever it was, it wasn't my father. It might have been an old man, trembling and staring into eternity, whom I helped, avoiding the puddles of his exploded bladder, to dress and who staggered out on my arm, but he was not in the least like, bore no resemblance whatsoever to, my father." Here, Broyard utilizes metaphor as a powerful tool to represent suffering of the physical body.

Many writers try to find a language representing the felt experience of those aspects of illness underrepresented by such narratives. The description of physical pain, emotional suffering, and the way bodily damage affects the self and other aspects of illness are indescribable including grief, despair, terror, and especially death.

When the attending physician tells the son "The cancer has reached his bones, I'll give him six months." The son wanted to say, "Why will you only give him six months?" But all he could ask is "Are you going to take him in as a patient?" The doctor removed his pince-nez and responded, "We don't keep incurable cases." The son with Broyard's classic humor quipped - "No, you send them packing." Then he bit his lips to stop hysterical laughter. The art of creating such vocabulary to describe pain, suffering, and death is difficult. Pain is the key secret on how to find the words to tell the story. How to understand that someone's death is not just the utterances from the sufferer entering death, but rather a story that has a shape. Death is the relationship of the living and the dying, those who are left with those who leave- and by its own authority, we know very little about it. The inside story is not limited to those who have died, it will happen to every person who lives and we are uniquely positioned as members of the ISHLT to tell these stories.

The loss of the father's stature prepares the son to take his place. Like most death stories, this is one about the coming of age for sons and daughters. Diving deeper, Broyard's What the Cystoscope Said demonstrates yet another obvious story, involving nurse and patient/family relationships. With the nurse's help, the son is able to deal with the internal suffering caused by the death of his father. The nurse is described as an "advertisement of life in this gray ward of old men with erectile dysfunction." Broyard explains that "...by sympathetic magic he resuscitates..." his father and the other failing men who view the nurse tending them in their hospital ward "...more mirage than oasis." The son asserts his virility in a dominating way as he performs a service for his father and these other impotent men who are deprived of their dignity, strength and power. In this hospital or any hospital today, we are reminded how decimating growing old, weak, and dying is, in terms of strength and virility. In terms of transplantation, our patients are rejuvenated; they have a new life or a new lease on life, a rebirth.

With death or the dying self, writers frequently refer to darkness, another location, tenement or country as unfamiliar grounds. Thomas Wolfe wrote: "I've made a long journey and been to a strange country, and I've seen the dark man very close." In Robert Frost's poetry we have, "I have been acquainted with the night" while F Scott Fitzgerald writes, "in the dark night of the soul it is always three o'clock in the morning." Night is the time when fear of death takes over and metaphorically, it is the time when a person encounters his or her darker feelings. Some are afraid of the dark and some are afraid to die. When death is expected with relatively little pain, people think and describe their feeling about dying in language. However, when someone is wracked in pain in the throes of death, language ceases to be a possibility. Uttered random words or sounds devoid of meaning such as a cry moan, or shriek may come out. This is probably why we have no description from a person who is dying of what this experience is really like. All we can do is witness the dying person or dying body.

How do we let go? Do we remain "Frozen." This process is described as mourning. Freud writes "when someone that we love dies, we learn not by volition, but by reality. We learn to sever the connections and remove the ego's attachment from the person who is no longer alive. This is a difficult procedure that takes a long time. All bonds uniting us to our loved ones must be brought up and cut one by one - mourning. Once severed, the ego becomes free and uninhibited then by nature and not by morality. Then, the ego attaches itself to something else. Living organisms maintaining connections with something no longer real learn to cut their losses." Freud's definition of mourning promotes the modern self to simply sing "Let It Go" like Elsa from the Disney Pixar Movie.

In stark contrast, Linda Pastan's moving poem "The Five Stages of Grief" focuses on the reality principle challenging Freud's theory. She suggests that the memory of loss is a reversal to cutting bonds or letting go. A memory is a way of making sacred the emotions retained from a lost love. When those we know and love die, they never die in us. Told from the perspective of husband and wife, readers witness death and its altering affect. In oneself, after the death of a significant other, one is changed through mourning. I have lost you.

Moving from a child or spouse witnessing death to the actual dier, we turn to Tolstoy's The Death of Ivan Ilyich. Ilyich's death begins like most deaths, as a newspaper event. We learn about the deaths of most people we know in the obituary column.

Like a son who takes the place of a father after death, someone else can take their place within the bureaucracy of the workplace or society. Upward mobility depends on death; therefore, death is not just a moral issue, it is Faulkner's mobility. There are also economic issues and pragmatic moves that occur.

Moreover, death is embarrassing. How do others, friends, and love ones behave during death? How do you conduct yourself?

Ilyich's lives a bland and secular life. He follows the rules. He does the right thing and goes through life in a perfunctory fashion. Like most people today, he is incapable of separating his job duties from his private life. Then Ilyich sees a new rival order in life with his wife's pregnancy. This disturbs him. There are childhood illnesses, life becomes messy and some of his children die. To cope with these changes, he shifts his focus further away from his family and towards his work as an escape. While moving into a new house and decorating he climbs a ladder and falls..."the biblical fall," then the pains begin and never go away. The physicians he turns to were not helpful. Not one of them addressed how serious his condition was and if he was going to die. The doctors' professionalism and conventions of their own field and mundane routine were no different than his. They ignored his dilemma. Towards the end, he realized he did not actually live. In the end, he suffers through three days of screaming then "he sees the light." He has acquired humility and generosity then enters a peaceful acknowledgement of death. In this story of dying is a story of living and a man's discovery that he has not live at all. ■

Disclosure Statement: The author has no conflicts of interest to disclose.

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