July 2, 1954, about 2:30 p.m. near Rush Hill, Missouri, on a brutally hot afternoon, an aircraft flies over a cornfield infested with grasshoppers. The pilot of the Piper PA-18A has been aloft most of the day, his alternate pilot is ill. The spray chemical is the highly toxic Aldrin. Shorthanded, the pilot has filled his plane with the noxious poison four times this day without the recommended gloves and mask. Guided by a ground spotter with a flag on a long pole, the bright yellow plane finishes a pass spraying less than three feet about the corn tops. The plane laboriously rises and banks to turn. About 125 feet from the ground, the heavily loaded aircraft stalls and plunges nose first into the earth with a ferocious and fiery explosion. The pilot - my father - John C. Hagan II, age 42, dies instantly. (See photo, next page.)
Thus was death suddenly, brutally, irrevocably visited upon our unsuspecting and unprepared family. The consequences of that sudden death, almost 60 years ago, resonate to this day. My mother, then age 37, my brother 5, my sister 8, and me, age 10, were left widowed and fatherless. Physicians and the general public knew little then about the pathophysiology of grief and grief recovery. There were no effective anti-anxiety or anti-depression medications. Psychiatric care was stigmatized and for “crazies and the near crazy”; there were no grief support groups. That generation’s answer was to “tough it out.”
Already an anxious child, I was told by everyone that came to express their regrets that “you’re the man of the family now and you have to be strong and brave.” A pretty formidable task for an insecure ten-year old boy that believed only very old people died and his parents would live forever. Another bromide repeatedly thrown at our family was “in time your grief will fade.” For my brother and me that was the case; ultimately we decided it would make our father sad to spend our lives raging at the vicissitudes of malevolent fate and the injustice of it all. My mother and sister never got over their grief, depression, and anger. Perhaps with better medical and psychiatric care they would have.
December 24, 2004. Audrain Medical Center, Mexico, Missouri. The patient is an 87-year old retired registered nurse who has long worked in ICU and surgical recovery. She has on many occasions fervently told her family that she does not wish to die hooked to a bevy of life support systems, especially a respirator. She has current advanced directives and limited power of attorney papers. Her quality of life has been good until about two years before this admission when she sustained a stroke. Debility and dependence progressed relentlessly. Now in a nursing home, she has not had a happy day since the stroke. She sustains an acute abdomen. Her surgeon doubts she can make it through abdominal surgery. The physicians and family explain to the patient they think this is a terminal event. If she lives through surgery it’s unlikely she’ll be able to get off the respirator or survive sepsis from the perforated viscus. The alternative is to give Schedule IV narcotics and keep her pain-free and gently sedated until she dies. She indicates she wishes the surgery. Her family is incredulous. They ask again, “Do you understand you will likely die hooked up to all those machines? You told us you never wanted to do that!” She nods and reaffirms she wants the surgery. She dies several days later, unable to speak and physically uncomfortable due to the respirator. The constant spectators embracing her in death are the medical instruments that she has always called “those damn machines.”
John C. Hagan, II, commercial pilot and charter member of the Missouri Pilots’ Association, left a young family of three after a dying suddenly 1953 in a fiery crash while crop spraying in a light plane.
Thus did my mother pass, and leave my sister and physician brother orphans.
Did she die a good death? Which course of action should her surgeons and family have followed? The oft stated wish to withhold extraordinary treatment at end of life? Or the decision of a very elderly woman with her a brain damaged by stroke and likely impaired judgment? Questions like these and the difficult decisions they engender are everyday occurrences for many physicians. Missouri Medicine will study them in this series.
Missouri Medicine began to feature theme publications with “End-of-Life Issues” (November/December 2002) and “Care of the Dying Patient” (January/February 2003). The manuscripts came from the University of Missouri School of Medicine and were coordinated by Contributing Editor David Fleming, MD. A widely used medical textbook (see sidebar, next page) was developed from those articles.
Over the coming two years, starting with this issue, we will revisit death and dying and consider what advances have transpired; what challenges and problems remain. My parents’ deaths illustrate many of these: how to handle the inevitable physical and psychiatric problems of family and friends after a loved one’s sudden death? How do physicians deal with the grief, anxiety, depression, rage, and uncertainties of the patient and family faced with a terminal illness? Thankfully, we have moved past two former problems: whether to tell the patient they are dying and abandoning dying patients’ mental, physical, and spiritual needs by sticking them in an out-of-the way hospital room. There to be neglected by their physicians and nursing staff because “They’re dying and we can’t do anything for them and the other patients need us more.” Regrettable actions that must never occur in contemporary medicine.
What constitutes “extraordinary measures” at end-of-life in a patient that wishes to decline futile medical heroics? When is “Do Not Resuscitate” the best possible medical care? What can we do to make the dying patient comfortable, pain-free and not feel isolated? What are our skills and attitudes towards providing care to the dying and dealing with their family and friends? Do we feel death is a failure and repudiation of our physician skills? What are our beliefs and comfort levels with contemplating our own deaths? Kenneth Murray, MD, on page 372 presents the case that physicians may face death with more equanimity and tread a different path than most of our patients at end-of-life. Missouri Medicine will update best practices for end-of-life problems and care of the dying patient (and their grieving family) using a distinguished group of internationally acclaimed authors.
And what happens during the act of dying? Our best answer comes from people that almost die but return to life and recall events that occurred while emergency resuscitation, critical care or surgery was performed to snatch life back from the jaws of death. Their recounting often factually refutes our physiological concept of consciousness residing in the functioning brain. As our medical and surgical skills increase, we can bring back sojourner patients who have traveled farther on the path to death than at any other time in history. What is a “near-death experience”? The term was coined by Raymond Moody, MD, in 1975 in his seminal book Life After Life, which is a perennial best-seller; over 13 million copies sold to date. Doctor Moody’s summation of his peerless life’s work appears on page 368.
The Near-Death Experience (NDE) part of this Missouri Medicine series will be the most encyclopedic and up-to-date in the world’s literature. We used two criteria when recruiting authors: 1) physicians or evidence-based medicine researchers in the field of near death experiences (which includes several prospective studies); 2) physicians who have themselves had a near-death experience. The response to our invitations has been 100% and includes two physicians that now have best-selling books on their NDE, Harvard neurosurgeon Eben Alexander II, MD, and Jackson, Wyoming, orthopedic surgeon Mary Neal, MD.
We scrupulously avoided recounting of NDEs by non-physicians. Too often these people follow this suspect sequence: report a NDE, write a book on their NDE that purports knowing the meaning of life, the answer to what happens after we die, and confirms that there is a heavenly life after death. Then they start giving seminars, lectures, paid consultations, writing more books, sell DVDs, blogging, and shilling on their website. NDE-related money soon constitutes the bulk of their income. Like the long ago purveyors of ectoplasm, there is a fringe commercial NDE industry whose testimony lacks credibility. We eschew this element. Lastly, we physicians must learn how to appropriately deal with our patients that report a NDE. They are much more common than you think.
Metaphysics includes the study of cosmology, epistemology, and ontology. There are many metaphysical questions that are encountered in NDE study. NDE reports challenge many of our deep-seated medical beliefs about what happens to the mind and consciousness at the threshold of death. They make us reflect, perhaps with some discomfort, on mankind’s oldest and most profound questions: Why are we here? Where does consciousness reside in the sentient being? What is life all about? What happens when we die? And lastly, mortal man’s transcendent question that science will never answer but forms the bedrock of religion and spirituality: What happens after we die; is there an afterlife?
It is summer of 1952 in my home town of Mexico, Missouri. The day is as perfect as God has ever made. I am 9 years old and my cousin Jim is almost 11. We are inseparable friends and live only two blocks apart. The halcyon summers of our youth seem to last forever. I assume that Jim, being 18 months older and more experienced, has all the answers. Jim does nothing to disabuse me of this belief.
Playing in a ditch outside my home, on an impulse I ask, “Jimmy, do you think we will ever get old and die?” He thought for a few seconds then said, “Yes, but that day is so far away it will never get here.”
Jim died last year at age 69. What was death like Jim? Where are you now? I guess we all just have to wait and find out ourselves. I miss you Jim, part of me died with you.
Biography
John C. Hagan, III, MD, FACS, is a Kansas City ophthalmologist and Missouri Medicine Editor since 2000.
Contact: jhagan@bizkc.rr.com
