Sunday, October 16, 2011

What is Death

I've only had to declare death a couple of times. Once in a three-year-old and once in an adult. In each case the heart had stopped beating. Death was clear.

Brain death is tougher to cope with, both clinically and psychologically. I imagine it would make anyone want to say, at some point, "Are you sure? Are you really sure? How do you know? How can you be sure?" Some times when brainstem function is gone and seems clearly irretrievable, there remains a good, strong heartbeat. Strong. Vital signs vigorous.

At one point this month, as I often do around Halloween, I was watching an old episode of the T.V. Show Ghost Whisperer. I enjoy ghost stories. I think whether or not one believes in a soul that can live on after bodily death, ghost stories can be interesting and appealing because everyone can relate to the feeling of being haunted or wanting to haunt. Even the impulse to visit places we haven't seen in years is this kind of gravitation toward haunting. The place still haunts us, and we want to return to haunt it for bit.

In this episode the main character, who is able to see and speak to spirits, receives signs and visions from a man whose body is in a coma but whose soul longs to break free and move on. His family is reluctant to remove life support, so he remains tethered, unable either to wander as an earthbound spirit or cross into a realm of peace that lies beyond this world. Every time I walk into an ICU I think of this episode. Even if ghosts and spirits don't exist, how can we know whether some remote corner of a patient's consciousness feels this sense of being trapped, tethered to ventilators and tubes?

If a family makes a decision to release their loved one and permit the life-giving gift of organ donation, I think of how painful it must be to leave the bedside for the last time. I've heard the sobbing of parents and siblings as I've waited to bring a brain-dead person to the O.R. for organ removal. I've watched a woman tearfully thank the doctors and nurses on her way out of the ICU for the last time as she leaves her sister in our care. I've looked down at someone younger than myself, thinking, "Your life was just starting," and felt sick and sad. Yet the automatic drill sergeant in my mind kicks right in: Not now. No time for feelings now. You have a job to do. Make sure all the families waiting for new beginnings today have the best, most well-cared-for organs you can help this patient provide. But I feel sick, I want to say. I want to cry. No. No sick. No cry. You do what you have to do and cry later. So that's what I do.

Anyone who wonders why an anesthesiologist would be needed for organ donation by a brain-dead person clearly has no grasp of what an anesthesiologist's job is. An anesthesiologist's job is to keep a patient's organs well-perfused and well-oxygenated. Usually this is synonymous with keeping a patient alive under anesthesia. In this special case, it means keeping the patient's heart and lung functions stable so that the donated organs can continue to give life in another or several others. I won't lie and say this type of case feels just like any other, even like just another cardiac case. It doesn't. It's strange. The patient is dead in the ways that matter most to his or her loved ones but alive in ways that will matter to others. Dead but not completely dead. I am taking care of a living shell of someone. A body that is dying and that eventually will come to a full stop.

For the anesthesiologist that moment comes when surgeons cross-clamp the aorta (and, if the heart is being removed, cut the heart out). After that, we can just walk out of the room. For the transplant surgeons it's just the beginning; after about four hours of harvesting they must rendez-vous with the organs and recipients at their respective medical centers and keep operating for eight or ten more hours, this time to put the harvested organs into hopeful people who have been waiting for this new start. For us, though, it's time to turn off the machine and leave the patient behind: the only time we ever leave a patient unattended in the room. This always feels eerie and wrong, but after all, what is there to do, when there is no beating heart left, no circulation, no breathing? And at some point, there is an almost-palpable change in the energy in the room. The person does indeed become a shell, with none of the vibe given off by a living individual.

Afterward all sorts of thoughts swirl around. What if that had been my loved one? Or me? What would I have wanted done, or done differently? I had ice cream last week. I hugged the person I love most in the world last night. This person will never do either again. I want to see Florence again before I depart the universe. I want to make croissants from scratch. I want to hear my son play the Bach Double Violin concerto, which he's starting to work on. I want to laugh really hard at a play with my daughter. What else should be on my bucket list? The thoughts just keep coming, when there's time and space for them, and Mr. Mental Drill Sergeant no longer needs to keep me task-oriented.

Organ removal is even more humbling, I think, than cardiac surgery. It's a concrete reminder of our own fragility and our tenuous hold on life. Lately I've been researching my children's ancestry on their father's side as well as mine, and as I go back and back and back many generations, and see birth dates and death dates and marriages - all huge events when we go through them, but mere drops in the ocean of time when you see them listed over the years - I can't help but think of how paradoxical it is that we are so small and insignificant, yet so dear and so meaningful. I also realize that what we pass on in terms of ideas and good actions is so much more important that what we pass on chromosomally. Our lives are so brief, then death comes for us all. There's no avoiding it. This moment is all we have.

Time to go and make the most of it.