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When Death Approaches

The Will to Live

The will to live is capricious, tenacious, and poorly understood. At times it seems to have little to do with the medical care we provide or choose not to provide for our patients.

A dying person's relatives will frequently ask me to prognosticate: How long will he live, doctor? It is a tempting trap to make such predictions. The longer I practice medicine, the more I realize what an impossible task this is.

I am convinced that some dying patients consciously forestall their imminent demise by sheer force of will. I suspect that others don't understand what keeps them going in spite of seemingly insurmountable odds.

I recently saw an elderly woman who had a chronic lung disease that made it difficult for her to breathe. She was having a severe episode and was sent to our department from the nursing facility where she lived.

It quickly became apparent that she was dying. She was in a coma and a simple test told me that her body wasn't getting enough oxygen to survive. I was faced with a difficult decision--Should I try to save her life with the aggressive use of drugs and a ventilator machine to breathe for her?

Technically, this is not all that difficult to do; in fact, we do it all the time. What made the decision difficult was the knowledge that sometimes, especially in the elderly, patients are never able to regain the ability to breathe on their own. The person we have "saved" may be stuck with a tube down his throat for the rest of his life.

Fortunately, in the case of the elderly woman, her brother turned up to help me make the decision. He told me the following story. His sister had suffered a serious infection of the brain as a young woman. It had left her with severe permanent brain damage and the mental capacity of a three-year-old child.

He described how he had cared for her all her life. He had taken all the appropriate steps to become her legal guardian. Recently, he too had been ill and had needed to send her to the nursing home to receive the care she needed.

And then something ironic happened. With tears in his eyes, he begged me to let her die and release her from the 60 years she had been trapped in her maimed condition.

This was ironic because throughout his telling of her tragic story, I had been thinking how cruel it would be to prevent her from dying, especially with the possibility of being further trapped on a ventilator. In my work, I see too many relatives who don't understand when it is wisest to let their loved ones go in peace.

I gently informed him that I could easily understand and respect his wishes. I reassured him that I did not think she was currently suffering, and that if she was, I could treat her with sedatives to ease her passing.

Then came the familiar question. I told him that it seemed unlikely she would last longer than a day. We agreed to send her back to her home and let her die there.

I went on with my work, feeling comfortable that I had made an accurate prediction and that, in this instance, doing very little to save a life was the right thing to do.

At the end of my shift, I called the nursing home to see whether my patient had died yet. They informed me that, contrary to my dire predictions, she had woken up several hours after coming back. She was now quite hungry and asking when dinner would be ready.

I felt a strange rush of emotions. A part of me was chagrined that I had been so fooled by this old woman. Another part was saddened because I knew her brother would be denied the relief he sought from his lifelong burden.

Mostly, I felt just a little bit wiser, reminded yet again that the will to live runs deep. For her own mysterious reasons, this woman was not yet ready to die.

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