The Way We Die Now (2 page)

Cork, in the south of Ireland, 1972 – I was twelve years old. My mother woke me very early, maybe at 5 or 6 o’clock. She told me that a neighbour, a boy of twenty-one, had been killed in a car crash. His parents could not face the visit to the morgue to identify the body, and this task was delegated to my father, who was a close friend. I attended the funeral with my parents; my two younger brothers were left at home. The coffin was open. His battered face was still handsome, but even I could see the undertaker’s work. Grown men were weeping. There was no consolation, only anguish. His mother mourned him for another forty-two years, the last ten in the mist of dementia. She went on to bury two more of her five children. One of the unexpected benefits of dementia was her belief that her favourite son was still alive. She died at ninety.

My mother’s close friend M. gave birth to a baby boy around the same time I was born. They were in the same ward in the maternity hospital. After a series of chest infections during infancy, the boy was eventually diagnosed with cystic fibrosis. In the 1960s, children afflicted with this condition rarely survived beyond their teens. The boy didn’t live to be a teenager. M. still sends me a card for the big birthdays; my milestones a reminder of her lost child.

Essex, 1980 – I had a summer job, working as a nursing assistant on a geriatric ward in a run-down hospital on the outskirts of London. The ward staff were a mixture of the good and the not-so-good, the hard-working and the lazy, and the patients were given as much comfort and care as the circumstances allowed. The ward sister was a genial, slightly mocking lady, who would often give me a gin and tonic after a particularly hard shift. The doctors attended infrequently, and showed little interest. The consultant appeared perhaps once a week, and was guided quickly around by the sister, who made sure he took no big decisions. Most of my patients were elderly men with dementia. My job was to get them up, wash and shave them, and feed them, a truly Sisyphean task. It was a good experience for me, but a miserable life for my patients.

I noticed that dementia took different forms. One man retained a degree of insight into his affliction. He put a great deal of effort into his appearance: he was ‘dapper’, in the way that working-class men of his era were. His hair was brillantined, he had a little pencil moustache, and wore a silk dressing-gown. He maintained a public carapace of jaunty, cockney cheerfulness: ‘Musn’t grumble!’ He had lost one of his legs (below the knee) to smoking-related peripheral vascular disease, so he was prone to falling. Longing for death, he died after a fall. He had no visitors.

Another of my men told me the same story every day: he had been a driver for the British army during the war, and on one occasion he had driven Winston Churchill and King George VI. His eyes would fill with tears as he recalled it: ‘The King of England and the greatest Englishman what ever lived!’

My oldest patient, Tom, had fought in the Somme: you could still feel the copper wire that had been used in the field hospital to bind his shattered knee. His only remaining pleasure was smoking, although he did enjoy the sensation of being shaved. In those days, smoking was allowed on the wards, and one of my jobs was to roll his cigarettes and light them for him. I fed him slowly, spoon by spoon, much of which he spat out. This task created a strange, intimate bond between feeder and patient: if he was in a good mood, he called me ‘good old boy’; if he wasn’t, he called me a ‘fucking c***’. Because he was somewhat deaf, the only way I could communicate with him was to affect a cockney accent. He was indifferent as to whether he lived or died. He had a large and devoted family, who visited frequently, and spoke to me every day about him. They were stunned by the decline of their patriarch. He died one night in his sleep; I was off-duty and learned the news when I came in for the early shift. It was imparted by the ward sister with her usual note of rueful, slightly indifferent, resignation. There was some discussion, I recall, about how the copper wire in his knee would cause problems with cremation.

An elderly retired doctor lived with his wife in an annexe of the nurses’ home. He had worked for many years as resident medical officer at the hospital, never climbing any higher on the career ladder. He liked to chat with me and my two classmates who had come with me to work in the hospital. He boasted one evening, in his cups, of killing off many ‘hopeless cases’ by injecting them with large doses of morphine: ‘Best thing for the poor buggers.’ Harold Shipman, too, killed his patients with morphine, although this drug is not especially effective for the task: the Dignitas clinic in Switzerland, which knows a thing or two about killing people, does not use morphine.

Cork, 1984 – I was the Senior House Officer on call that day for General Medicine. The switchboard put through a call from my youngest brother, phoning from home. My father, aged seventy-one, had collapsed outside the house, while walking the dog. My brother called the ambulance. I dropped everything and drove the short distance home. The ambulance was just leaving when I arrived. My father was taken to the resuscitation room of the emergency department. I stood at the door, and watched the scene unfold. He was not breathing; a tube was inserted into his airway, and a team of junior doctors started giving him cardiac massage. It wasn’t working. I indicated to them that they should stop, and they were happy to comply. Had my brother not called me, I would have been a member of this Cardiac Arrest Team, running down to the resuscitation room, not knowing whom I was going to be faced with.

Sudden, premature death was common among the men on the street where I grew up. R. – a few doors up – dropped dead, aged forty, leaving a wife and six children. S. – two doors down − died of a heart attack, aged sixty, leaving five children. D. – three doors up − at the age of fifty, collapsed, and died of a ruptured abdominal aneurysm in the ambulance. My mother still lives – alone – in the same street; many of the houses are now occupied by widows.

I have worked as a doctor for more than thirty years, nearly all that time spent in large, acute hospitals. Death in modern hospitals still has the faint whiff of an industrial accident, a failure of medical intervention. When I was a student, treatment of the dying was briefly and fleetingly covered − death being a ‘negative outcome’. We – the medical profession – had begun to believe in the delusion that we could tame nature, that all illnesses were potentially curable. Yet death was all around – in the wards, in the resuscitation room, in the morgue.

In those days, before the scandals about organ retention, many, if not most people dying in hospitals underwent a post-mortem examination. When I was a medical student, we were required to attend at least twenty post-mortems. These were surprisingly sociable events, with a large crowd of jostling students nervously and obligingly laughing at the pathologist’s jokes. The process involved in dissecting a corpse to establish the cause of death is indescribably gruesome, and I thought at the time that no family would consent to such a procedure if they could witness what actually goes on. I watched as the lungs, upper airway and tongue were removed in one piece. I saw how the skull was opened with a drill to extract the brain. I saw the bodies of dead babies and old ladies and young suicides. I had fallen behind in my attendance, and towards the end of the year there was a serious risk that I would not reach the required minimum of twenty. I was friendly with one of the pathology registrars, who would let me sit in on post-mortems at weekends, so I sometimes saw several on a single visit.

I should add that post-mortems were not as shocking for us medical students as they might have been because we had experience of the dissection room. The first visit to this room was, I admit, disconcerting: the overpowering smell of formaldehyde, the waxy, almost unreal corpses. We learned very little of lasting value over the two years spent carrying out dissections in the anatomy department, and I felt guilty that the public-spirited volunteers had donated their bodies for so little benefit.

During my first three years as a doctor, I was regularly part of the cardiac arrest team when I was on-call at nights and weekends. This showed me death in the raw, chiefly because cardio-pulmonary resuscitation was then (and still is) so spectacularly unsuccessful. Very often, we were ‘bagging’ with oxygen and cardiac-massaging people who were well and truly dead, the team called only to keep up appearances. It was not unknown for a nurse, having found a patient dead in their bed in the middle of the night, to call the arrest team, thus giving the impression to the relatives that she had chanced upon the patient just at the moment when they stopped breathing and had acted with the utmost diligence and initiative. Perhaps the most bizarre arrest call was to attend a patient who had jumped to his death from the top floor of the hospital, down to the concrete below. His mangled body was beyond fixing.

I was struck on more than one occasion by the sheer terror of those few still conscious near the end. One man has stayed in my memory. It was a Saturday afternoon in Bradford Royal Infirmary, Yorkshire, sometime in the mid-1990s. I was senior registrar on call for General Medicine, and was summoned to see a man in the Coronary Care Unit. He was in his mid-fifties, admitted to the unit with a myocardial infarction (heart attack). He had severe chest pain and breathlessness. I gave him an injection of morphine, but it didn’t work, and he looked at me with a twisted rictus of fear, the physical expression of pure horror. His heart stopped beating and we failed to resuscitate him. He died, his last conscious sensations being those of pain, the struggle for breath as he drowned in his own bodily fluid, and terror. The deathbed was the usual scene of a blue and battered corpse, oozing blood from all the punctured arteries and veins, surrounded by empty syringes, blood-stained sheets, and a silent arrest team.

Another man haunts me too: in his forties, he was admitted with a flare-up of his asthma. The arrest team (of which I was the most junior member) was called because he had suddenly become extremely short of breath. When we arrived on the ward, the man was blue and gasping for air. We didn’t know what was causing this. He was given oxygen, but did not improve, and stopped breathing completely. The most senior member of the team, the medical registrar, tried to intubate him, but instead of placing the tube in his trachea (windpipe), he placed it in the oesophagus (gullet), which resulted in a violent expulsion of vomitus. By the time the anaesthetics registrar arrived, he was beyond rescue. A post-mortem examination showed that he had a tension pneumothorax: the lung had suddenly collapsed. Not one of us had considered this as a possibility. Pneumothorax can be treated – relatively easily – by placing a drain in the chest cavity.

But life goes on, and after a few glasses of wine at home, you move on to the next day, the next awfulness. Doctors, unlike, say, soldiers or policemen, rarely admit to being affected by the horrors they have seen, and are seemingly immune to post-traumatic stress disorder.

Perhaps this immunity is partly owing to the fact that, although we see it every day, doctors do not think very much about death and dying. In my case, one of the reasons this became so was a procedure called percutaneous endoscopic gastrostomy (PEG). My specialism is gastroenterology, and much of my work is performing endoscopic procedures. PEG is one such endoscopic procedure, which I first carried out in the early 1990s. It involves the placement of a feeding tube through the abdominal wall, directly into the stomach, bypassing the mouth and gullet. PEG tubes are commonly inserted in patients who cannot eat or swallow. Most of these patients are old and frail.

This procedure was first described by two US surgeons, Jeffrey Ponsky and Michael Gauderer in 1980, and was initially used mainly in children with severe neurological disability. After doing this procedure for some time, it gradually dawned on me that in most patients PEG was futile and potentially harmful. Many people with dementia were subjected to the procedure, despite the fact that several studies had shown that it did not prolong life, improve nutrition or prevent suffering. People who had sustained a severe, incapacitating stroke, with no prospect of recovery, were kept pitifully alive by it. There were lengthy and complex legal disputes revolving around PEG feeding of individuals with persistent vegetative state in Britain and in the US, in the respective cases of Tony Bland, who suffered severe brain injury during the Hillsborough disaster in 1989, and Terri Schiavo, who was left severely brain-damaged having been resuscitated after she had a cardiac arrest at home in 1990.

In 2002, I happened to be at the annual meeting of the American Gastroenterology Association in Atlanta. This meeting attracts up to 15,000 delegates from all over the world; the atmosphere is one of pomposity and hubris. At the end of a ‘plenary’ session on endoscopy, Jeffrey Ponsky was presented with an award, honouring his contribution to the speciality. Before the handing over of the actual award, we were treated to a short film about the great man. I learned that he was keen on horse-riding and country music, and that, way back in the 1960s, his mother-in-law had loaned him the money to buy endoscopes when he had a hunch that this would be the future. As I sat in the vast auditorium, I reflected that Jeffrey Ponsky’s co-invention of PEG was not an unalloyed boon to humanity.

Over time, I became increasingly uncomfortable carrying out the insertion of these feeding tubes, and invested a lot of time and psychic energy in trying to dissuade families and well-meaning colleagues from authorizing the procedure. Eventually I reached the uncomfortable conclusion that, in most cases, this form of feeding was instituted mainly to meet the complex emotional, professional – even economic – needs of families and care-givers, rather than those of the patient. PEG, in many cases, was a technical panacea for existential problems.

This fact, of course, was unacknowledged, or was actively denied. It is much easier, for example, to feed elderly confused people by PEG than by the slow, laborious, sometimes frustrating and expensive (in terms of labour costs) method of spoon-feeding. PEG feeding is a superficially attractive solution to all forms of eating difficulties in the frail, the old and the dying, but comes at a high price, with the risk of the procedure itself, along with chronic problems of aspiration pneumonia, diarrhoea, tube leakage and infection. More importantly, it turns the ordinary human activity of eating into a medical intervention, and deprives people of this simple pleasure. I actively – and successfully – resisted pressure from other doctors to insert PEG tubes into the dying. The procedure became for me a symbol of the medicalization of death, and of the failure of modern medicine to care humanely for those most in need of its help.