Several months ago, I committed to “just slow down,” to reduce computer worship, and to be more present and thoughtful. Well, the report card is in: moderate effort; minimal progress; see teacher after class. For a pathological overachiever this failing grade is unsettling. I had set out to conquer electronic addiction and black mirror distraction. Instead I am still pacing the bottom rung of our 12 step programme. All this despite knowing the only truth that really matters: you know that we’re all going to die, right?
Despite my advantages—or perhaps because of those advantages—I have found confronting the big truths to be darn hard work. It is always easier to buy something shiny, and there are no shortages of self-aggrandizing distractions. Presumably it is no different for our patients, and I will endeavor to cut them some slack. Forget transcendence, after only a few days of internet sobriety I fell off the wagon with an embarrassing thud. It was even too hard to replace the hard liquor of screen time with the near beer of a good book. Who’d have “thunk it”: change is as tough as platitudes are easy. Apocryphal Granddad was right: if I really wanted to change I would have done so already.
Focusing on what really matters takes old fashioned grit and new fangled insight. We clinicians ought to have both. Our job at the business end of life and death should mean that we accept what most people ignore: life is a terminal event, and no cash, nor fame will change that. To quote Stratford’s favorite son, “all that lives must die.” To quote my equally sage spouse, nobody will care in 50 years.
Maybe I can blame my genes and ancestors. After all, presumably my forebears were selected for action, not for deep thought. They would have gone hungry had they contemplated the impermanence of life, let alone the sound of one hand clapping. However, epigenetics is increasingly making the case that our choices and environment can turn on and off methyl groups and histones throughout our life. Moreover, these changes in genetic expression may endure for generations. Think of it like a series of light switches, and we have both the on-off variety and those fancy dimmer switches. If true, then we can influence our genetic lottery, and that of our offspring. If I needed a scientific rationale to do the right thing I now have one.
In contrast, there is a growing trend towards nihilism and tribalism. Regardless of one’s politics there is something concerning about a world with Trump on one side of the pond, Brexit on the other, and a flotsam tide of dissatisfaction all around. It is hardly surprising that to most people Nirvana is a 90s grunge band, and that yoga is more about buying designer stretchy pants. It seems like chutzpah to implore people to find meaning and give gratitude, but this may be our best medicine. Similarly, it seems laughably anachronistic to remind healthcare workers that we are lucky, not cursed, to serve others. Wish me luck as I try chanting that mantra during the next thankless shift.
If we at least accept that every journey starts with a single step then I’ll offer this binary proposition: it is great to be alive, and it will be fine to be dead. Unfortunately, modern medicine is increasingly creating a state that is neither fully alive nor fully dead. While the movie Princess Bride has been, ironically, quoted to death, Billy Crystal’s character makes a prescient observation: “mostly dead is slightly alive.” Modern medicine excels at keeping people alive long after they can recover or thrive. There can be lawsuits for those that refuse to acquiesce. There is also money aplenty to be made from administering a literal death of a thousand cuts. Technology has become simultaneously too easy to start and too difficult to stop. The next medical revolution should be to regain humanity and relegate machines. We need to relearn how to die because it is going to happen—spoiler alert—to every darn one of us. No matter how starched your white coat is, doctor, one day you’ll be taking a dirt nap.
It is likely part of the human condition that we would rather dismiss death with a joke than face it head-on. Woody Allen is credited with saying: “I am not scared of dying, I just don’t want to be there when it happens” and Spike Milligan’s tombstone reads: “I told you I was ill.” However, the statistics are clear and cold: you are increasingly likely to “be there when it happens.” You are also far more likely to have endured increasingly frailty as opposed to sudden death.
Approximately 75% of Westerners now die in hospital, 25% of those in intensive care, and more and more following lengthy battles. Most relevant is that many of us will also die with regrets. Surveys suggest that we are likely to wish we had lived a life truer to ourselves, to have not worked so hard, to have expressed our feelings clearly, to have kept in touch with friends, and to have allowed ourselves to be happier. Fortunately, there is still time. Unfortunately, it is also later than we wish to believe.
Peter Brindley, professor in the Department of Critical Care Medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton, Canada. Twitter: @docpgb
Competing interests: None declared.