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GENTLE DEATH OR A CIRCLE OF HELL?
HOSPICE CARE CAN MEAN THE DIFFERENCE BETWEEN THE TWO

He's lying on the hospital bed wrapped in white plastic, all taped shut. He's still somewhat warm, though he died four hours ago. He has the residual glow halfway between the radiance of the living and the flat stoniness of the cadaver.

The family has been in, spent their time with his body, prayed for him, and now they're gone, and the nurses have wrapped up the body for transport down to the morgue. The toe tag pokes out through the plastic. I touch his arm, and it still moves freely; rigor mortis has not yet set in.

Through the plastic, I can still see how he's swollen from edema, the fluid collection in the legs and arms that tells of last-ditch efforts to keep him alive with IV fluids.

He died on eight medications, including IV antibiotics for the pneumonia we suspected. He died without much pain killer or distress-relieving medication, because they can make you drowsy and the medical team was hoping he would come out of his coma. He died with a huge, flabby heart, crippled by congestive heart failure, prodded by several heart medications, including one that was putting him into kidney failure.

All these things had very little chance of working. But there was uncertainty. The medical team was stuck between a very faint hope of recovery and the strong evidence that he would die soon. And when a family is given that formulation, given that interpretation of the situation -- "There's a small chance he might pull through if we do this" -- what can they do but say, "Try it"?

Sometimes I think the price of our hope is the torture of our elders.

There is a relatively new medical approach called hospice care, designed to ease the transition from life to death. Hospice doctors and nurses don't really worry about giving too much pain medication or prolonging a painful life a few more weeks.

This patient would have benefited from it, but the uncertainty stood in the way. There are no numbers to tell us with certainty when death will come, so we don't always know when to call hospice. Who wants to be a doomsayer, anyway? It's easier sometimes just to hope and push onward.

So the medical machine continues the tests and treatments it is designed to perform: nuclear scans, ultrasounds, angioplasties, surgeries, chemotherapy.

You as patient get nauseated and constipated. There is pain and then embarrassment as you are rolled half-naked down a public hallway.

And every night in the hospital a nurse (following doctors' orders) wakes you up to take your blood pressure, and every morning a phlebotomist sticks you for blood, and twice a day they come at you with a heparin shot to keep clots from forming in your legs.

Maybe you're hard of hearing and you can't understand what people are saying to you, and there are new people coming into your room every eight hours anyway. God forbid you have a touch of dementia and can't remember faces or situations or even what year it is.

How terrifying that must be.

There is an established psychiatric syndrome called "lCU psychosis," wherein patients begin to hallucinate, hear voices and develop paranoid ideas after a few days in intensive care -- just from the stress of it.

What is the big difference between all this and some circle of hell?

On another floor of the hospital, a quick patient-transfer away, the hospice doctors and nurses have a few rooms. I've seen a few patients die there.

They're soft rooms, with homey curtains and pictures on the walls, and things are quiet.

Given a choice, nurses there will make a patient drowsy with morphine rather than let them be in pain. They'll clean up frequent accidents rather than leave uncomfortable tubes in.

This can cause conflicts with physicians practicing the more traditional, aggressive medical approach.

But I've seen patients who seem to enjoy the peace that comes with acknowledging that the end is near, who have time to say goodbye to their families with meaning and thoughtfulness, rather than catching a last glimpse of them through the feverish pain of a final battle.

And death, when it comes, is gentler.

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