Memento Mori

It was a busier shift than usual because the day team from the day before was one physician short so they shifted the doc who was supposed to work 6pm-4a to 3p-3am and he stopped seeing patients at 2am in order to wrap. This left me to take care of everyone from 2am-6am. This ED (emergency department) is one of the few I’ve worked in where it’s as busy at 4am as it is a 4pm. It is what it is!

Just as I thought that I was winding down, EMS brought in a 76-year-old man with end-stage metastatic lung cancer who was in a nursing home for palliative care (meaning that he and the family had accepted that he was going to die and that there was nothing else that could be done except for comfort care until that moment arrived). He had signed a “Do Not Resuscitate” (DNR) order, which meant that in the event that he should die, he didn’t want us to perform cardiopulmonary resuscitation or to put him on the ventilator to breathe for him.

He reportedly started vomiting the day before and during the night became very short of breath and was in respiratory distress. When EMS brought him into the ED he was unresponsive and his respirations were agonal (taking his last breaths). I was somewhat confused as to why he was brought into the ED because he was in the nursing home for palliative care and was DNR. EMS stated that his wife wanted him intubated. I had the DNR documentation that he himself had signed three weeks before when he had capacity (decision-making capacity).

I called the wife to explain that her husband knew that he had end-stage cancer and signed that he did not want to be intubated or resuscitated when this moment came. This was the entire purpose of being in hospice care and requesting DNR (Do Not Resuscitate). She stated that she understood this but wanted him intubated and placed on the ventilator (“breathing machine”) to keep him alive just long enough for her and his family to arrive and say goodbye to him, and then she would request to have him taken off the ventilator.

This is the type of ethical dilemma that emergency physicians face on a daily basis. On the one hand, it is a relatively straightforward issue in that he had made a request to not be resuscitated in this circumstance, and I had clear documentation of this so I could easily abide by the patient’s request without fear of legal repercussions. However, there is the human perspective. The wife and family are about to lose their loved one and simply want to say goodbye while he was still alive. It is facile to state from a medical perspective that he was already unconscious and would not be aware of their presence. However, losing a loved one is a strong human emotion and for that family, this seemingly simple act of saying goodbye could mark them for the rest of their lives.

I didn’t have to face that decision because the patient died during our phone conversation. My plan would have been to put him on BiPap (a noninvasive method of breathing for him) to prolong his life enough so that the family could arrive to say their goodbyes, but I would not breach his request to not be resuscitated with CPR or any heroic measures. When the family arrived, they were obviously distraught but were understanding and happy to know that he did not suffer. We allowed them to stay in the room with him in order to grieve and say their goodbyes.

Afterwards, I thought about how privileged those of us who work in emergency departments and similar settings are to have the opportunity to witness death with such frequency. We for the most part have become numb to it, likely a subconscious response to protect ourselves, and take it in stride. “It’s just part of what we do.” The reaction of the staff after pronouncing someone dead is often no different than after lancing someone’s boil and discharging them home. By the way, I’m not suggesting that it should be different but am simply making an observation. The one exception, however, is when a child dies in the emergency department. The emotions in the resuscitation room are high and when the child dies, tears well in everyone’s eyes. There is the notion that adults already lived their lives and in some cases, contributed to their deaths; or at the very least, we shrug it off as it was just their time to die. With children, there is an innocence that makes it impossible to rationalize or sugarcoat and by the end of the resuscitation, there are at least one or two of the staff that can be found bawling in a corner.

It was in one of Jed McKenna’s “Enlightenment Trilogy” books that I was introduced to the term “Memento Mori,” which means remember your death. Western society doesn’t have a strong relationship with death. We treat it as a pariah, whereas in some other cultures it is treated with veneration and respect. In one of Carlos Castenada’s books, he describes the shaman Don Juan Matus explaining to his apprentice that in indigenous cultures death is their friend and always walks close on their left side as a reminder that they too will die. I’ve heard that in India, the grey ash worn on one’s forehead is to remind those passing you that they soon will be dust. I remember the shaman, Don Diego, who would begin many of his ceremonies by saying that we were all going to die. He reminded us that to be reincarnated as a human being with consciousness was a great gift and that the purpose of this was to evolve. He added that to live this human life as though we were immortal and not focus on our spiritual evolution was a waste of this gift. In other words, he was saying “Memento Mori,” and to take advantage of the short time we had in this human form.

How many people do you know who have even discussed their deaths or the deaths of their loved ones? Surprisingly, even when loved ones are terminally ill, their death seems to take us by surprise. How would your life be different if you knew you were going to die in a week, a month, or six months? How would treat others in this circumstance? How would your relationship change with someone if you knew they were dying?

I feel that as medical professionals, we are privileged to be witnesses to death on a regular basis. It’s an opportunity if we don’t become numb to it in order to hide, to ask ourselves these questions that have the opportunity to transform our lives. They push us to evolve beyond our metro-boulot-dodo lives. But for most all of us- 99%- it’s a missed opportunity. The knowledge that we will die- Memento Mori- is a gift. It’s a reminder that we should live, cherish life, and not focus on the minutia that so often occupies our energy and life force. If we’re lucky and have the grace, we may even have the opportunity to die in this human life before we die and awaken to our true nature.

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The author was born in Haiti and has lived in New York City for the past 54 years. He is a practicing emergency physician who has dedicated his life to the healing arts and the exploration of Consciousness and creativity.

He self-published his second novel "Love in the Time of Coronavirus: 20/20 in 2020" on Amazon (https://www.amazon.com/dp/B09BZLVKP4).

He & his wife are presently on a world-travel adventure that he is writing about in his blog "Travels with Ale." For exciting & thought-provoking content, & to be part of the adventure, follow him here, on Instagram (https://www.instagram.com/richardlanoix/) & Facebook (@RichardLanoixAuthor· Author). His other blog posts related to Consciousness can be found at medium.com/lanoixvisions.