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- Yesterday7 min
Friday Reflection 64: Accepting the End
Sally: Henry said you could have a year.Betty: And what would that year be like?Sally: I’d be with you. I won’t let you give up.Betty: I know that. But I watched my mother die. I won’t do that to you. And I don’t want you to think I’m a quitter. I fought for plenty in my life. And that’s how I know when it’s over. It’s not a weakness. It’s been a gift to me. To know when to move on.Betty (handing Sally an envelope): These are instructions. Open it the minute you know I’m gone.Sally: No!Betty: Listen to me, things happen very quickly when people die. Henry’s not going to be able to handle things.Sensible Medicine is a reader-supported Substack. If you appreciate our work, consider becoming a free or paid subscriber.You can rely on me to watch epic television about a decade late. In the last five years, after the kids left home, I have watched The Wire, Breaking Bad, and Better Call Saul.Mad Men was my most recent way-too-late watch, so this scene with Betty and Sally is fresh in my mind. It comes from the penultimate episode of the series, The Milk and Honey Route. (At this point, I feel I don’t need to alert readers to this spoiler.) How Betty Draper Frances faced her prognosis reminded me of one way I’ve seen people face their ends.The average age of patients in my practice is about the same as the average American life expectancy. This means that I spend a lot of time dealing with death: diagnosing life-threatening conditions, collaborating with colleagues to manage those illnesses, and discussing people’s end-of-life care.Although the processes of dying might be enumerable — Sherwin B. Nuland mastered that in How We Die: Reflections of Life’s Final Chapter — we humans are too varied to reduce how we approach death to a dozen or so types. To paraphrase Osler, there might be a finite number of ways to die, but there are an infinite number of ways to react to our mortality.Betty is an archetype of the patient who accepts what is to come. I realize that I don’t really know my patients’ reality. What looks to me like acceptance is a patient sharing something that looks like acceptance with me. That said, some people do react to certain death without anger or sorrow or resignation, but with acceptance. I hear from these patients that they have appreciated their lives, understand that there is little left for them, and that more time only means suffering for them and their loved ones.Even within acceptance, there is diversity. An oath of confidentiality, and a whole lot more, keeps me from sharing case histories, but three composites summarize the experiences, wishes, and challenges of people memorable for their acceptance of the coming end.FP was a 90-year-old woman who lived with the same cancer for 12 years. While the first recurrence was devastating, each subsequent recurrence was met with a shrug. Through her late 70s and 80s, we — and by we, I mean her oncologist — managed her cancer as a chronic disease. During these years, she lost her husband of over 60 years, dozens of friends, and one child.When an X-ray, ordered for a lingering cough, revealed lung nodules “too numerous to count”, she was clear that her years of treatment were over.I saw her with her surviving daughter, I’ll call her Theresa, whom I had occasionally seen at her mom’s appointments. Theresa clearly loved and respected her mother and was grieving the coming loss. While FP was certain that she wanted no more treatment and requested that I commit to making her end as painless as possible, Theresa nudged her mother to accept more treatment. FP wanted to spare her daughter watching her mother die a prolonged death; Theresa could not face the loss of the mother she had always relied on.LS was 80 when he came to the office after a hospitalization. It had been 18 months since I had last seen him, and the history, presented by LS and his son, made it clear that in the months prior to the hospitalization he had experienced cognitive decline.He was hospitalized with an acute delirium, caused by urinary sepsis. Even by 21st-century standards, the hospitalization had been miserable. For the first two days, even as his infection came under control, he became progressively more delirious. He spent two days in restraints and two more with “a sitter” before he was well enough to be discharged to subacute rehab.I saw him about a month after discharge. He was living at home and had a home health aide who spent 4 hours with him each day. The delirium was past, but the dementia was obvious. His short-term memory was poor, and word-finding difficulty affected the rhythm of our conversation. His insight was, maybe tragically, intact. As a man who had live
- 3 days ago42 min
This Fortnight in Medicine XXXVII
Predictive Utility of Coronary Artery Calcium Score Added to the PREVENT Atherosclerotic Cardiovascular Disease EquationsContinuous Glucose Monitoring in Non–Insulin-Treated Type 2 Diabetes This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe
- 2 weeks ago30 min
This Fortnight in Medicine XXXVI
Supplemental Vitamin D and Incident Fractures in Midlife and Older AdultsCatheter ablation for symptomatic atrial fibrillation (PVI-SHAM-AF): a randomised, double-blind, sham-controlled, multicentre trial* This Week in Cardiology with John M. Mandrola MD* Cardiology TrialsAnd a special treat/rescouce we have covered nearly 100 articles at this point on the podcast. Here is an active list of all the articles we have discussed. Take a look, read the articles, and refer to our conversation if you wish! This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe
- 3 weeks ago32 min
Lecture 9 - multiplicity
This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe
- Oct 7, 202638 min
This Fortnight in Medicine XXXV
Colorectal Cancer and Mortality Risk Among Older Adults With vs Without Adenoma on Prior Colonoscopy* The Hubris of Screening for Disease — AgainPrognostic Value of Blood-Based P-Tau217 Levels for Progression to Cognitive Impairment* Why Blood Tests Are a Poor Screening Tool for Alzheimer’s This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe
- Sep 23, 202631 min
This Fortnight in Medicine XXXIV
Cancer-Related Mortality Among US Pilots and Flight AttendantsResponse-Tailored or Standard-Duration Antibiotic Treatment for Infective Endocarditis This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe
- Sep 22, 202619 min
Lecture 8 - endpoints
Our free series is almost over This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe
- Sep 15, 202629 min
Lecture 7
New lectures coming soon (after part 9) This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe
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