Saturday, January 31, 2009


Recently, the media has been enchanted by a 33 year old who delivered via C-section a full set of octuplets at a hospital in Bellflower, California. Such multiple gestations have only become a reality with assisted reproductive technology. But they are extremely dangerous for mother and children. This is not a desirable outcome. It may even be unethical on part of the health care provider. If this was done through in vitro fertilization, that many embryos should not have been transferred. The risks of multiple gestations include stillbirth, prematurity (as was the case here at 30 1/2 weeks), low birth weight (here, the smallest was 1 lb, 8 ounces = 680 g where an average birth weight is 3500 g), cerebral palsy, and need for neonatal intensive care. For mother, there is a much higher risk of C-section. But even beyond that, there are so many social factors to consider. This mother already has 6 children. How is this going to impact her family? How will it impact the future of the children? Though it is impressive that 46 well-orchestrated medical personnel accomplished such a feat successfully, it really isn't ideal at all.

Friday, January 30, 2009

Pregnancy Options

In one of our classes, we were asked to consider our own preconceptions and opinions regarding pregnancy, abortion, and adoption. For example, how do we feel about an undesired pregnancy that is carried to term? An undesired pregnancy that is aborted? A pregnancy that a family cannot financially support carried to term? Or an abortion undertaken solely because of financial reasons? Are there any circumstances in which a woman should not carry a pregnancy to term? What if it was a result of rape? Or if the woman is a drug addict? Or even if the parents are simply divorced? Are there any circumstances in which a woman should not be able to choose abortion? What if the baby is just poor timing; she wants to have one, but not for another year? What if she is coerced by her partner?

Ethically of course, the woman can decide to carry a pregnancy to term or elect an abortion. But how we feel as providers can easily change the tone of a conversation or sway a patient's opinion. Like psychiatry, we have to watch our internal emotions regarding these personal and charged topics. Countertransference can be a powerful subconscious presence in these situations.

I was personally most struck by questions of adoption. How do I feel about women carrying a pregnancy to term intending to put their infant up for adoption? Is it permissible if the woman cannot financially support the baby? What if she only wants to do it for career reasons? What if she wants to do it because the pregnancy was unintended and she does not want an abortion? What if she wants to do it because the baby has a congenital defect? For me, putting up a baby for adoption has a lot more impact because such a decision imposes a further burden on another person or society in general. I'm not sure how the value of autonomy in a pregnancy should be weighed against beneficence to the infant or justice with respect to societal resources.

Thursday, January 29, 2009

Operating Room Gynecology

I spent this week with the benign gynecology team. It felt very surgical. There is a small inpatient service at Mount Zion (one of UCSF's satellite campuses) and most of our day is occupied by operations. Over the week, we've had a few operative hysteroscopies, using a scope to look inside the uterus to assess for things like fibroids, retained products of conception, and arterio-venous malformations. We've had a laparoscopic ovarian cystectomy and an open ovarian cystectomy, a laparoscopic hysterectomy and an open one, and an abdominal myomectomy. It's always fascinating seeing the same procedures done in different fashions for various reasons (for example, we were worried that one rapidly growing fibroid was a leiomyosarcoma so we did it open instead of laparoscopic). I've also seen a few D&C's (dilatation of the cervix and curettage of the uterus).

It's fun being in the operating room. It reminds me strongly of surgery. I like the setting and the satisfaction of dissecting out the pathology. It's nice to have familiarity with the tools, approaches, thought process, and techniques of surgery. I also realize that an ob/gyn's surgical repertoire is fairly limited. Even though they do laparoscopic, open abdominal, and transcervical procedures, the bulk of diseases I saw involved fibroids, ovarian cysts, uterine bleeding, and pelvic pain (there's also the field of female incontinence).

Tuesday, January 27, 2009

30 Years of Medicine

We had a lecture today from a very entertaining professor, Dr. Nachtigall.

"I'm impressed by you guys. Medical students these days have to learn so much. They say medical knowledge doubles every ten years. Since I went to medical school, there's 8-fold more knowledge. In fact, back in my day, we learned the head with one mnemonic: TEON."

We looked at him with earnest ears.

Dr. Nachtigall gestured at his facial accouterments. "TEON: Two eyes, one nose." He then pointed at his legs. "The other one that we learned was LEG which stands for: lower extremity, ground."

Clearly, the mnemonic to differentiate between arms and legs.

Monday, January 26, 2009

Poem: Inauguration


It’s like coming home, this georgic grace
that sweeps the cornfields, causes stalks to twitter,
telling us that unfortunate truth: those we love
are never the ones who love us.
I yearn to regale you with virtues,
my ambitions, my glorious and refined,
but hesitation holds me trigger-fingered
for history runs rampant today, and I
would be remiss if I did not tip my hat to those coffers
and say my sin is one of pride,
just or unjust, shining and shameful
a funeral cloak to send smoldering
on the coals of time’s descent.
You could not know
You could not know because you are popular,
you are popular as the sun, popular
as the ruddy tinged cheeks, popular
as a Cadillac shimmying up the driveway.
You never had a moment of want,
suitors fell at your doorstep,
a suite of tutors, a tower of books
a host of dreams and a Greek play too,
you’ve had everything but this
so I linger, phantom between apology and arrogance
because this could have been anything
ten dozen cranes, an origami fleet sailing
to another time, perhaps
when you would have forgiven me.

Saturday, January 24, 2009

Stop the Bleeding

My friend and fellow blogger Stephanie gave me sage advice about this rotation from her dad, an ob/gyn. "Stop the bleeding," he says. Unfortunately, I learned this well on my last call night when one patient's peripartum plight became more and more worrisome.

This woman had a prior C-section and was attempting a vaginal birth after C-section ("VBAC" or TOLAC = trial of labor after cesarean). Attempting a normal vaginal delivery with a previous surgery on the uterus carries a risk of uterine rupture, a life-threatening condition for mother and fetus when the womb tears open from the forces of contractions. Some institutions including UCSF support women choosing VBAC by offering in house anesthesia, close monitoring, and experienced staff. Our patient had a constellation of poor risk factors. She was post-term (41 weeks+6 days). Although she had broken her bag of water, she was not in labor (premature rupture of membranes), and as a result, was at risk for infection (chorioamnionitis). After reviewing risks with her, we decided to augment her labor with pitocin. While benign and standard for a regular laboring patient, pitocin for her carried further risk of uterine rupture (1-2% rather than 0.8%).

Even with gentle pitocin augmentation, she wasn't progressing; the cervix was minimally dilated and effaced, the baby was at a high station. But we kept going until about 9 at night when a nurse called for a doctor. The patient had a large episode of painless vaginal bleeding, about 500mL (the same volume as a bottle of water). We were worried; the whole team rushed in, two attendings and the anesthesiologist were at the bedside, and we were evaluating for fetal distress and uterine rupture. But the baby was doing fine and the patient's vitals were stable. A cervical exam by the resident was "weird"; the cervix did not feel normal, and the baby's head could not be palpated. A bedside ultrasound confirmed the diagnosis; this was a previously unknown placenta previa (the patient's care had been transferred from an outside hospital and they did not know this).

We then decided to C-section the patient; she and her husband agreed to the plan. She lost another liter of blood during the spinal anesthesia. We had two IVs but one stopped working. Her blood pressure dropped to 60/30mmHg before we managed to transfuse two units. When we crash sectioned her, she lost another liter of blood. Baby was out and doing fine. But the placenta took a lot of negotiation; part of it may have been overlying the previous C-section scar and grown into the tissue of the uterus (previously unknown placenta accreta). We worked hard to stop the bleeding, managing to evacuate all placental tissue. We typed and crossed her for a few more units.

A few hours later, a nurse called us from the recovery room where the patient passed two "baseball sized clots" per vagina. She was still bleeding. The resident and the attending did several attempts at manual evacuation of clot. The uterus was pretty "boggy", the word we use when it doesn't clamp down to prevent bleeding. While the rest of our body clots to stop bleeding, the uterus, a muscle, needs to contract. If stuff is in the uterine cavity, whether placenta or clot, the uterus cannot contract effectively. So the resident and attending manually scraped out clots. We gave some methergine and hemabate but she bled liter after liter of blood.

Normally after every surgery and delivery we estimate blood loss. A normal blood loss in a vaginal delivery might be 350mL; in a C-section, maybe 800mL. Above 500mL in a regular delivery and 1L in a C-section, we consider a hemorrhage. The proverbial 70kg man has 5L of blood. Here, our patient lost 500mL before reaching the OR, another 2L in the OR, and now 2L post operatively.

The resident initiated a massive transfusion protocol, treating this patient as if she were a victim of a car crash or had a heavy gastrointestinal bleed. We called the blood bank to get more blood and fresh frozen plasma (containing coagulation factors). We were afraid she would go into DIC - dissminated intravascular coagulation - due to depletion of coagulation factors. The anesthesiologist toyed with the idea of inserting an arterial line and transferring to ICU. We finally stopped the bleeding with a Bakri tamponade balloon, exerting intrauterine pressure.

In the end, the patient remained stable, and the baby was healthy. After transfusion of five units of blood, we normalized her lab values. But throughout the night, her course was tenuous and prompted us to think of many critical care issues that we normally do not deal with on labor and delivery. Always stop the bleeding.

Friday, January 23, 2009

The Bird and the Baby

The title of this post refers to The Eagle and Child, a pub in Oxford, England which boasted patrons such as JRR Tolkien and CS Lewis. Now of course, it makes me think of the proverbial stork delivering babies to expectant mothers (how much easier that would be, I realize).

My three weeks on labor and delivery have been awesome. I've delivered seven babies, and it's really fun. I've gained a lot of confidence in delivering healthy newborns and learned a lot about the process and experience of the laboring patient. The first moment that new parents realize they are such is truly amazing; the cry of relief, the tears, the thrill and happiness - it's pure magic. I've seen the spectrum of deliveries: a multiparous woman going from 2cm to delivery in several hours, the patient whose induction takes 4 days, the stoic who needs no pain relief, the passionate who fights through the pressure, the hysteric who needs every skill, tool, and word of encouragement we can muster. I've seen single moms, lesbian couples, first kids, fifth kids, fifteen-year-olds, forty-year-olds, extended family, terrified husbands, resolute boyfriends. Though normal pregnancy, labor, and delivery can be routine, there's a lot of fun and joy in getting to know everyone involved and seeing them triumph over these challenges of mother nature.

In addition, I've participated in a few C-sections and a tubal ligation, reminding me how much I like the operating room setting and dissection. I've assessed patients in triage for preterm labor, mastitis from breastfeeding, and bogus chief complaints (a fifteen year old came in with her friends because they wanted to see the fetus on ultrasound). But the most interesting patients are often transferred from outside hospitals or fetal treatment patients. We've had a twin gestation where one twin has a life-threatening arrhythmia; how do you selectively control one twin's heart rate? Can you convert someone in utero? We have people with peripartum cardiomyopathy, twin-twin transfusion syndrome, and unstoppable preterm labor. Some transfers are unbelievable: a 23 weeker who was delivered by crash C-section at an outside hospital for an unclear indication (very sad case, the baby is going to die and the mother is a 17 year old). Some transfers are fascinating: a repeat C-section for a patient with achondroplasia. The fetal treatment center here takes patients whose fetuses have complex cardiac defects; I've seen several pregnancies complicated by hypoplastic left heart syndrome, double outlet ventricles, transposition of the great vessels, and coarctation of the aorta. Those deliveries are particularly high energy, with pediatrics and cardiologists standing by to resuscitate if needed.

So as a whole, my time here has been lots of fun. I've learned a lot and realized the intersection between solid medical complexity and pregnancy - maternal-fetal medicine - is really thought-provoking and intricate.

Image is a Victorian postcard, in the public domain, taken from Wikipedia.

Thursday, January 22, 2009

Longitudinal Clinical Experience II

I wrote a previous post on the patient population at my longitudinal continuity clinic. My LCE is in hematology and oncology. It's a very different experience than standard clinical rotations. Though it is outpatient clinic like family medicine, heme/onc is so much more specialized and management-based. We see a lot of breast, colon, and prostate cancers along with a few leukemias and lymphomas. The hematology side varies a lot, from increased clotting tendency to leukopenia to thrombocytosis. Patients range in age, but most are older than 50. Our patients are all referred to us from other providers.

Cancer diagnoses are usually made by primary care physicians who send patients to us for chemotherapy. My preceptor knows in depth the various chemotherapy regimens and the evidence regarding new cocktails and combinations. There is very little diagnosis involved. A lot of it is finessing side effects, education, coordination with surgery and radiation oncology, and specific therapies. Hematology patients vary a lot more. Consults range from benign "reassure the patient" to acute myelogenous leukemia. There's a lot more diagnosis, analyzing lab values, and problem solving.

In terms of content, I've realized outpatient oncology does not thrill me. I'm not hugely interested in learning the nuances of chemotherapy regimens. But it is fascinating to see the wide range of cancer presentations, from breast cancer in a 30 year old to a metastatic prostate cancer in a 90 year old. I really enjoy the hematology; the diseases there are so weird and interesting.

I am learning an incredible amount about how to relate difficult diagnoses and end-of-life considerations. My preceptor is incredible when talking to patients, building a solid foundation of rapport and trust. He approaches difficult topics directly, easily, and deftly; even when giving a young patient a terminal diagnosis, he frames the conversation in practicality and hope. He explains statistics and prognosis in a surprisingly clear, straightforward, and accurate way. He is able to sympathize with patients yet avoid being consumed by the intense emotions and serious topics. These skills are the hardest to learn and sometimes, the most useful.

Tuesday, January 20, 2009


Image is from Wikipedia, in the public domain.

Monday, January 19, 2009

Evidence Based Medicine and Ob/Gyn

Unfortunately, some routine things in ob/gyn have little evidence. For example, fetal heart monitoring is standard of care today because of medicolegal precedent. Intuitively, monitoring the fetus' heart rate seems like a good idea; it's one of the few noninvasive ways we have of seeing how the fetus is doing. But there's no evidence suggesting that monitoring leads to better outcomes for mother or child. Indeed, the evidence suggests monitoring increases only one thing significantly: rates of c-sections (which we would like to avoid).

Indeed, how much medical intervention is appropriate in the process of childbirth? For thousands of years, women have been giving birth without the help of doctors. And they were doing well. Now is our medical meddling worthwhile? Is it beneficial for the mother and baby? Is it cost-effective? Certainly we would like to think we do no harm. But a hospital is an instutition, sterile and unwelcoming. Would women feel more comfortable delivering at home? Would babies do better in that environment?

To give credit where it is due though, Pap smears have the best evidence in my opinion of reducing cancer-related mortality. While there's never been a randomized controlled trial, the epidemiology, both in the U.S. and worldwide, is compelling.

Sunday, January 18, 2009

Poem: Faces of Labor

Faces of Labor

I thought the pushing would bore me,
mommies all with the same thing,
a child leaving the house
kicking and screaming all the way back,
but past the constipated breathing
the condensation on her forehead
the salmon-cheeked boyfriend
I see women completely different:
the seventeen-year-old determined to forgo
the epidural, boyfriend bewildered,
the multip with twenty family and friends,
infants to great grandparents celebrating,
the solitary lawyer whose father waits outside
with the seventy year old vet,
husband of room three, a nurse whose love
dismisses second looks and stares.

In labor room six, a new age biology teacher
dances, nude, her belly flowing from corner to corner
shiny as the full moon, and I cannot help
but imagine her baby, heart at a hundred twenty
beats per minute, counting out a polka
or samba, a mirror image of the mother
twirling in a trance, drawing in unseen energies
traversing territory I had never believed
but was been paved thousands of years ago.

White Cloud

It may be premature to say this but some follow-up to the crazy raining babies that was Friday afternoon (two posts ago). We have to take a 24 hour weekend call and I'm at the tail end of it. It's 0430 in the morning, and I'll jinx it by saying it's been dead quiet. We had a few triage patients but otherwise they call it a "white cloud" - everyone's tucked into bed. Crazy, huh? It sort of sucks as a medical student cause we want business, but the team is so much happier, able to tie up loose ends with our patients and get rest.

Image is from Wikipedia, shown under Creative Commons Attribution 3.0.

Saturday, January 17, 2009

Delivery Note Template

Excerpt from a June 2000 publication in the American Journal of Obstetrics and Gynecology:

"A 10-year-old, captive-born female gorilla, gravida 3, para 0, aborta 2, was observed to be in labor at term after spontaneous rupture of membranes. After 36 hours of observation, she had not yet delivered her infant. A team of physicians and veterinarians intervened. After induction of general anesthesia, an assessment of fetal and maternal status was made. With ultrasonographic monitoring of fetal cardiac activity, labor was augmented with administration of intravenous oxytocin. A vaginal delivery was performed with a vacuum extractor, resulting in the birth of a viable, 2.4-kg female infant. The infant survived the neonatal period and was hand reared until she was successfully introduced to the gorilla troop at the age of 1 year."

Friday, January 16, 2009


Today was a crazy day. At one point, we had nine women in labor. Six of them were complete (cervix dilated and effaced) and began pushing at the same time. It was really crazy! We ran around, catching babies door to door. I delivered two today, plus a C-section! Hopefully I'll find some time on call tomorrow to blog properly.

Thursday, January 15, 2009

Trial of Labor

I had seen labor and delivery once previously, and it's really amazing. It awes me to think that this is the renewing process that has persisted (obviously) through all of humankind. Generation after generation, women have undergone this trial of labor in solidarity. And now, participating in some peripheral role, I have stepped into the lives of these women, routine deliveries for me, but pivotal life events for the patients and their families. I am awed in watching this intensive, emotional, and triumphant sequence of events and humbled that I can take part. Perhaps one day, clamping and cutting the cord, turning the placenta as it comes out, counting out the pushes may become banal, but I hope that first moment - the cry of the baby, the delivery onto a maternal abdomen, the wide smile of relief of new parents - that those things never lose their magic.

Wednesday, January 14, 2009


Some of the nomenclature in ob/gyn is interesting. While we might call this the miracle of birth, it's also a product of conception after its estimated date of confinement. Personally, I would never think of such wonder in the sterile language of medicine.

Image from Wikipedia, shown under GNU Free Documentation License.

Tuesday, January 13, 2009


I'm doing obstetrics at Moffitt-Long, the academic hospital which handles high-risk antepartum patients as well as the usual labor and delivery; here, we do fewer C-sections and more forceps assisted deliveries. In our orientation, we reviewed pelvic anatomy, suturing, how to deliver a baby and assist a C-section, and the breast and pelvic exam. Then we were sent off to our labor and delivery floors.

The team composition for L&D here is different and makes sense for obstetrics. There is a day team and a night team whose shifts overlap slightly for patient sign-out. This is in contrast to the call team and nightfloat system seen in medicine. Having two consistent teams is great for laboring patients; they know all the people that may potentially be involved in their delivery, day or night. It's also nice for continuity for the medical student. I think the residents work really long hours compared to other services though; plus, being on all nights is brutal. I really like my team; resident and intern teaching are outstanding and rival the teaching I've gotten on any other rotation.

We have didactics every Tuesday morning which approximates the lecture time on other rotations but is really tiring since it's given as a bolus. Otherwise, most of my time is spent on labor and delivery. We take four overnight calls, but we get the following day off.

We see four types of patients. Antepartums are pregnant patients admitted for issues from preterm labor to twin-twin transfusion syndrome to maternal arrhythmias. They're very interesting medicine-like patients. We then have triage which fields ob related urgent care like mastitis or possible labor or pre-eclampsia. We have our laboring patients, which I'll write another post about. And finally we have our post-partum patients who have already delivered and are similar to post-surgical patients, low-maintenance and recovering.

Monday, January 12, 2009

Poem: Birth Day

Birth Day

From the insulation of a snow globe
the world’s sonorous music aches
yearns to resound with discordant
and majestic frankness

In a swell, a rush, a restitution of sorts
I fly, blue coattails trailing, a din of calamity
broken by a cry, taking breath
and breathtaking, the wriggle akin
to a dance you and I learned
so many years ago.

Free will
that breath which all at once, takes in love
misery, dream, deception, joy, and being
with great devotion, the stuff of philosophers
a curiosity that drives a contract with death
a lease out of confinement
into that embrace of sunlight
or at least, the San Francisco fog

Slippery, a fish out of water
gills like ears, for the first time free
of amniotic incarceration
recapitulating that magic
which charms and intoxicates
teaches us the beauty of metamorphosis

Saturday, January 10, 2009

Easy III

I guess this is a three post topic. Achieving the goals of medicine is easy. The ways to optimize societal health are clear. We need to reduce, then eliminate smoking. Patients need to get their health care maintenance, cancer screening, and vaccinations. Health care needs to be accessible to all people, and at the same time, primary care needs to be appealing enough for doctors to go into it. Fixing social issues will have an incredible impact on health: reducing fast food, emphasizing regular exercise, improving education, providing jobs. By eliminating disparities in other societal aspects, health comes easily. It's easy to figure out why the U.S. spends so much money in health care but has such poor outcomes. We aren't investing wisely; we put too much money into fancy pharmaceuticals, expensive technologies, acute care, and the end of life that give us little yield. We're focusing on the trees rather than the forest, and in doing so, we have mired ourselves so deep that we're having trouble getting out even though the solution is crystal clear.

Friday, January 09, 2009

Easy II

The counterpart to the last post is that the further one goes in training, the harder medicine gets. As a medical student, medicine is simple. We're taught knowledge at it's cutting edge; what we learn and see is the most evidence-based and current. We also learn "classic textbook" presentations of diseases. We do things based on the teaching, not experience, so we rarely face dilemmas. When we don't know something, we ask.

But as we become residents, we have to diagnose those odd-ball presentations. We have to build that experience to intuit whether nausea without chest pain could be a heart attack or dizziness could be a stroke. Few things are "textbook." And residents in the healthcare system are the workhorses, getting things done. At the same time, they are supposed to practice evidence based medicine, demonstrating quality patient-centered care. Indeed, the residents I work with can quote studies spontaneously, citing not only the major conclusions, but also the study's downsides. They work the hardest hours, they know the most, they make our system work.

And then we get to the attendings who have the hardest job. They exist to prevent people from falling through the cracks and to stop the cracks from widening. They teach, they are expected to be experts in what they do, and they are the source of much of our evidence base. They have to think ahead in what medicine needs both for a patient and as a field. They anticipate, they refute, they think.

Wednesday, January 07, 2009

Easy I

This is a two part post.

Doctors don't want you to know this: medicine is easy. It should be. We want to be right most of the time. We want to know what we're doing. And the majority of time, it's simple. Hopefully we know the patient who comes in because we are their primary care doctor. Much of the time, we can make an accurate diagnosis based on the history and physical exam. We send off a few tests to confirm. We may start an empiric treatment. Our diagnosis is correct, our management appropriate, and the patient is satisfied.

Countless doctor visits proceed in this fashion. It is the standard of treatment, it is the patient's expectations, and we've made it easy. Despite the long and severe training, anyone who gets through it is capable of being a doctor. Doctors and medical students aren't particularly brilliant. We work hard, enjoy learning, but hardly any of us are geniuses. Patients usually don't shop around for doctors based on their education; Harvard doctors aren't necessarily more sought after than other MDs. We trust that our doctor, by virtue of completing their training, is good enough to complete that simple task of diagnosis and management.

Tuesday, January 06, 2009

Checking All the Boxes

I'm not 100% sure this is an accurate statement, but here's a thought. When we order labs, it's easy to check all the boxes: CBC, chem-7, electrolytes, LFTs, pregnancy test, etc. But here's the problem: if you take a normal person and order 1 test, you have a 5% false positive rate (if the tests are calibrated to p=0.05). If you order 5 tests, you have a 23% likelihood of one false positive. 20 tests, and you're up to 64% likelihood of a false positive. If you order 100 tests on a normal person, you're almost guaranteed to have at least one false positive (99.4%). This is based on tests having 95% sensitivity which isn't horrible (though I admit many tests have better sensitivities than that). This is the reason why I think data mining microarrays is a statistically ridiculous idea.

Monday, January 05, 2009

Poem: hearth


whistling wind sanding her way into my head
tide’s frigid depth unrelentless,
secret-whispering, like the notebook you keep
hidden in your dresser
lists of lovers by lovers
shrapnel threatening this statue of a face
chip by chip until the only lines you can read:
despite cold or calamity, hurricane or hail,
home’s hearth persists.

Saturday, January 03, 2009

Free Will and Death

One of my primary philosophical interests is free will, which itself is a body of academia. In medicine, I've encountered questions of free will in surprising yet expected contexts relating to death and dying. Free will is the idea that at any junction in which we perceive ourselves making a decision, we have the ability to choose otherwise. It's an extraordinarily powerful drive, enabling us to pursue projects, take pride in our accomplishments, feel shame about our failures, and attribute meaning to our lives. Innately, we all understand this concept of free will as a component of raw human experience. Yet philosophers have found over time that pinning down and explicitly defining this noumenal thing is impossibly difficult.

We can control many things in our life. Against improbable odds - the laws of physics, the actions of our peers, the stock market - we are still able to maintain a set of actions and attributes that we feel are our own; we choose what car we drive, where we live, what we spend our evenings doing. Our free will is liberating, identity-defining. But as patients near the end of their lives, this sphere of self-determination shrinks. They may lose their ability to walk independently, to communicate, to think. Disease, frailty, and the finality of human experience chip away at this practical (rather than philosophical) free will until it edges the person out to the final choice, that of living.

Indeed, this may be what scares us about dying: the loss of choices, the loss of free will, the loss of some fundamental defining aspect of being human. Yet in some ways, this is obvious; what is death but the loss of the self? (Of course, some belief systems incorporate such things as an eternal soul). I found it surprising that my experience with patients and their families at a time of death and dying reflect this idea. Those deaths that are most peaceful are the ones in which the patient has not only accepted a loss of control but also freely given up their free will (if such an idea is possible). Those who have the most trouble have problems resulting from this pesky free will; they regret a decision they made long ago, they refuse comfort care measures, they believe sheer willpower will nourish them, they are anguished by impossible decisions that doctors force them to make.

Alexander Pope ("Essay on Criticism") said, "A little learning is a dang'rous thing; / Drink deep, or taste not the Pierian spring; / There shallow draughts intoxicate the brain, / And drinking largely sobers us again." American medical ethics, over the last few decades, has defined autonomy as an overriding ethical principle. We have moved from paternalistic doctor-defined medicine to a patient-centered model, intending this to be for the better. In the majority of cases, I agree. But I am on the fence regarding the most ethically-wrought cases involving death and dying. The hardest cases are the ones in which there is an overwhelming likelihood someone will die but a possibility they may survive if "everything is done." In the few cases that I've seen, shifting this decision responsibility to the patient (or worse, the patient's family) causes that person more pain than I think is justifiable. First, do no harm. But there is immense harm in perpetuating an illusion of free will at a time when someone is actively losing it.

These are just sketches of ideas I've had. They may not fully reflect what I believe, but I think they are interesting enough to present. I'll end with a quote from French philosopher and 1957 Nobel Prize winner Albert Camus:

"All that remains is a fate whose outcome alone is fatal. Outside of that single fatality of death, everything, joy or happiness, is liberty. A world remains of which man is the sole master. What bound him was the illusion of another world. The outcome of his thought, ceasing to be renunciatory, flowers in images. It frolics - in myths, to be sure, but myths with no other depth than that of human suffering and, like it, inexhaustible. Not the divine fable that amuses and blinds, but the terrestrial face, gesture, and drama in which are summed up a difficult wisdom and an ephemeral passion."

Thursday, January 01, 2009

Happy 2009!

I hope everyone has a Happy New Year and that 2009 is filled with friends, family, fortune, curiosity, pursuit of passion, and good health. Yesterday, while playing Mah-Jong, I found the tile above, fācái (prosperity), to be particularly apt.

I also learned recently of a fascinating phenomenon called the frost flower when thin layers of ice are extruded from long-stemmed plants in autumn or early winter. They are very pretty.

First image shown under GNU Free Documentation License. Second image is in the public domain, both are taken from Wikipedia.