Session Two: Time--Counting the Moments/
Making Moments Count

Guy Micco, M.D.
Alta Bates Hospital and Joint Medical Program, UC Berkeley

Comment

Dr. Tripathy talked about new technological advances in the treatment for cancer, and pointed out that they are small, really small, and that promising things are on the horizon. That is the same thing that I think he heard fifteen years ago when he went into practice, and the same thing I heard twenty years ago when I went into practice: things are on the horizon. Although Dr. Tripathy didn't label it as such, the problem of "informed consent" is bound up in all of this: how do we best help the patients who are vulnerable because they are sick make a decision to accept or reject a new treatment which may or may not be beneficial to them? Dr. Tripathy said that the process of educating patients to be able to make an informed consent is incredibly difficult. And it's particularly difficult in conveying this uncertainty that's inherent in what we're doing, or what we're asking the patients to take on in a treatment, in particular, in this case, the treatment for cancer. This, at a conference we had a couple of weeks ago, some of us called "the first error of physicians," not conveying that uncertainty to patients. I was happy to hear Dr. Tripathy say that that's one of the first things that is necessary to convey to patients. The statistics may show one thing, but the fact of what will happen in any one particular patient is unclear.

Why do physicians not convey this uncertainty? Either out of ignorance, or more likely, I think, out of an attempt to protect people from a potentially grim prognosis. We're very bad at talking about prognosis with patients. That was the subject of a study that came out recently, that some of you may have read about in the papers: physicians and oncologists don't tell the truth about what they feel is their best guess about prognosis, and they may not tell the truth to themselves. And the truth is that it's a best guess. But further, their best guess is often not conveyed to patients.

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Michael Witmore spoke about death in the early modern era and the fear of suddenness. I think of the prayer, "Oh, Lord, give me a conscious death." If that was the feeling of the public, well, it apparently has changed. It has been said that all Americans fall into one of two camps: either wanting to die consciously or wanting to go quickly. I suspect most people here would want to say that they would want to go consciously, but, think again, please, because it's not quite so clear as it sounds. If, in fact, this is the dichotomy, most commentators say that Americans want to go with their boots on or, alternatively, asleep. It appears that unconscious wins. A conscious death is not necessarily something devoutly to be wished for in our culture today.

Let me move to Dr. Schneiderman and particularly to his remarks on persistent vegetative state. Larry and I have had discussions about this before--we both agree and we sort of disagree. But as he knows and you all know, the value of life for probably most of us in this room is the value that we place on our personhood. We, not surprisingly, find it completely foolish to continue a life that's devoid of those characteristics that we find most valuable and important to us. That is, we don't place as much value on the mere fact of life. As Dr. Schneiderman noted, however, and as I'm sure you know, others have a different sense about it. The mere fact of human life is immensely valuable to them, even perhaps when faced with a loved one who is in what has been aptly but terribly called a vegetative state. I have no answer to this difference in perspective but it needs to be acknowledged.

Let me turn now to some remarks of my own. I'm going to start with an anecdote. This is the traditional pedagogical method of my profession--it used to be the preferred method; and although it's come into problem times, still, I think it's a good method to use. The anecdote is that of Mr. Reggie--clearly, not his real name. Mr. Reggie died in our local community hospital not too long ago. He died one of the ever-more-common planned deaths in the Intensive Care Unit. Planned deaths have been reported to be as high as 90% of Intensive Care Unit deaths. Two nights before his death he had had a stroke. It was a big one, with bleeding into his brain, and he became comatose immediately. He was 85 years old. That we know of, he had no pain, no anxiety, no need for symptom control. But just as the paramedics got him to the hospital, he had a respiratory arrest, he stopped breathing and required mechanical ventilation. When I saw him, he was in the ICU, the Intensive Care Unit, in a coma, on a ventilator, with his family around the bedside. We all agreed that he would not want to continue like this if there were not a reasonable chance for some recovery. After reviewing his brain CAT scan with a radiologist and a neurologist, it became apparent, quite clear, actually, that he didn't have such a chance. So Mr. Reggie's family and I decided that we would all meet at his bedside the next morning and turn off the ventilator, "pull the plug," in common parlance. We planned his death.

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The next morning, Mr. Reggie's wife and children and minister met me as planned at the bedside. I explained that I was going to turn off the ventilator, pull out the so-called endotracheal tube that had been inserted into his throat, the equipment that was delivering air or oxygen to his lungs. Since I believed that he would not be able to breathe on his own, I said that this would result in his death. I proceeded to do as I described and, indeed, Mr. Reggie never took a breath on his own. He was dead by one very old criterion.

But something unusual then happened at his bedside. Mr. ReggieÕs heart's EKG, electrocardiogram monitor, was on, just above and to the left of his head. And we all stood there transfixed by this electronic representation of his life, watching the ever-slowing tracing of the electrical activity of this man's dying, or what we thought was this man's dying, but not yet dead heart, and listening to its soft beeping accompaniment. Mr. Reggie was in some strange liminal state, as were we, for what felt like a very long time.

Then somehow--I have no idea how--perhaps it was my discomfort with what was happening, or perhaps it was a glance from his wife, something broke the spell, and I turned off the monitor, announcing at that time, as doctors are want to do, that the patient had died. The family then turned their gaze and attention to their beloved husband and father, and the minister said a blessing. But was Mr. Reggie really dead when I pronounced him so? The timing of death is important to us for a variety of good reasons. We want to be sure when someone has died. In the Intensive Care Unit, we want to be very sure that someone has died. It's not a place for these kinds of errors. "Dead?" "No, no."

Some might think, and some have told me, that this patient wouldn't have died until his monitor showed no electrical activity of his heart, that I shouldn't have turned off the monitor, or I should have kept watching the monitor myself at the nurse's station, and pronounced him dead when the electrical activity went to so-called "flat line." But virtually anywhere outside the Intensive Care Unit, unless the person is hooked up to an EKG, an electrocardiogram, at the end of their life, death is determined as it has been for, again, a very long time. You are dead when, first, you look dead--no movement and some other qualities, like, for instance, big pupils that don't budge when you shine a light on them. One of my colleagues, a seasoned oncologist, claims to know when someone dies, absolutely sure she says, when they have a waxen look to them. This happens "within a minute," she says. Within a minute of what is unclear. One might be concerned with the validity of this looking-dead criterion; it has a high sensitivity; there are no false negatives: when you're dead you always look dead. But its specificity is something short of 100%: not everyone who looks dead is dead.

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So the second traditional criterion of death is that you stop breathing for much longer than you can reasonably be expected to hold your breath. This is actually my preferred criterion. I'm with King Lear on this one. He stands over Cordelia: "I know when one is dead and when one lives," he says. "SheÕs dead as earth. Lend me a looking-glass, if that her breath will mist or stain, why then she lives." Or for a more up-to-date example, take a recent Stephen King movie (I was in the video store, finding something very highbrow, I assure you, to watch, and this was going on in the background). Two children are traipsing through a forest and come upon a third child, a non-moving child, one of the duo says, "He looks dead." And the other responds, "HeÕs not dead, stupid. HeÕs still breathing." It's part of our human understanding, I think, to equate breath with life. It is in our languages, the word for breath often being the same word as for spirit or life force. In fact, the first definition of "spirit" in WebsterÕs Second is "the breath of life, life or the life principle." Or take Genesis, Chapter Two, Verse Seven, "Then the Lord God formed a man, Adam, from the dust of the ground 'Adama,' and breathed into his nostrils the breath of life." Thus, to extrapolate, you die when you expire, when you breathe out your last breath.

You might consider now with me the power of the mechanical ventilator and what that has done in the last thirty years or so.

The third traditional way to determine death is when the heart stops beating. And this is actually pretty unreliable--it certainly was, for sure, before the invention of the stethoscope in the early ninetheenth century. A weak pulse, one sufficient for life can be very difficult to feel. And even with a stethoscope, some hearts beat faintly within and can be missed. Having done so, I can attest to this. Thus, the usefulness of the heart monitor, the electrocardiogram or EKG, which shows the electrical activity of the live heart. I'm not against EKGs, but I don't want to give too much over to them. In particular, I want to note that a heart's electrical activity is not sufficient for life, nor is its absence a guarantor of death. Specifically--I'm hoping here not to be too technical--the heart may have electrical activity as shown by a cardiogram or heart monitor that does not lead to the mechanical activity, the pumping of the heart, sufficient to sustain life. And the absence of this electrical activity is insufficient to call death because this activity may be restored within a few minutes. And death is irreversible, isnÕt it?

I will also take a cheap shot at the technology, by saying that it is liable to error. A so-called lead falling off, and a very live patient can look very dead on a cardiac monitor. The EKG is, thus, not a very sophisticated bit of technology, and though it's quite useful at times, it's a poor test and an unnecessary test for determining when someone has died.

So I've given some ways to determine if, and perhaps when, someone has died. I've evaded the simple yet embarrassingly difficult question: What exactly is death? I seem at once both to know and not know what it is. WebsterÕs Second says death is "the cessation of all vital functions without capability of resuscitation." But this, again, really speaks to the question of when death occurs: when all vital functions cease, without chance of resuscitation. So I'm going to take the chance and revive, again, a very old definition: Death is the absence of a life force. It occurs when the life force leaves the body. I don't know what the life force is, but I do know that breath and breathing are intimately associated with it. Thus, death occurs when we expire our last breath.

Now back, quickly, to my patient. At the end of his life, Mr. Reggie had a machine breathing for him, literally keeping him alive. When this machine was stopped, we watched as his last breath was breathed for him. As we observed his heart monitor, several minutes passed; he was not going to breathe again. His life force had left him; he had expired. The heart monitor, showing the heart's electrical activity, had really nothing to offer us, but we were for awhile so taken by this electronic technology that we tended more to it than to the real thing, the patient in the bed before us.

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