Wisdom
Death and the American Fighter
When is the right time for hospice, in a world that tells people not to give up?
Posted March 11, 2022 Reviewed by Kaja Perina
Key points
- It is important to understand the role of one’s fight for life and the wisdom to know when to surrender.
- To see the wisdom in opposites; explore how we face an opponent with armor vs vulnerability that lies just beneath.
- One can engage with one's own mortality at the end of life without having to aggressively pursue the limitless arsenal of medical care.
It’s a paradox.
We typically never want to get hospice involved too early for fear of abandoning hope or not allowing ourselves or our loved ones to not get the best and most ambitious medical care. But once we do that, once we get hospice involved, death is imminent.
The time spent getting aggressive care was not spent on “living,” perhaps and instead on fighting the disease. The actual time left for living was reduced to the fight and the rapid demise at the end. Is there another way of looking at this that would perhaps allow us more time to live without fighting?
It seems to me that if you’re an American, you most certainly are a fighter. That’s what I typically see and hear from most everyone I’ve treated when faced with a grave illness. Fighting is correct, fighting is the right thing to do, always! I recently helped take care of a frail lady in her eighties who was strategizing about her forthcoming treatment of a newly diagnosed metastatic lung cancer. She had met with her oncologist and with the palliative care team at the hospital and had decided to pursue chemotherapy and radiation therapy. I had asked her what made her choose that approach. Without any hesitation she told me, “I’d rather die of complications and side effects rather than give up on this.”
What concerns me about this response is not the fighting instinct. That I believe is innate in all of us. What intrigues me however, is the lengths to which we will go to not have to limit aggressive care.
Life in the Developed World Keeps Death Forever at Bay
We are fortunate enough to live in an epoch of high tech and affluence where mass access to medicine and medical procedures and interventions are the norm. We accept, by default, that diseases can be cured or at least kept at bay. Pain is not an option and suffering is a thing of the past.
Most importantly and profoundly however, our exposure to death has been effectively omitted from our young life’s experience. What I hypothesize is that because of our lack of exposure to dying at an early age, we never had the lesson of internalizing the awareness of life as being necessarily finite.
Early exposure to death connects death to the reality of life. Put another way, the person who acknowledges death need not suppress or deny it categorically. The experience of death during our formative years allows death an allocated space in our mental map of what it means to be human, and that makes all the difference. The learned acceptance of death as a part of life was the lesson given to our ancestors early on, so that its presence in later life didn’t seem as foreign as it does now.
The Fighter Mentality
One has to also consider the psychology of the fighter as he/she trains for and commits himself to the fight. No fighter comes into the boxing rink with the mental attitude of losing. There is an internal dialogue that starts early on and persists throughout the fighter’s training in having an absolute conviction of winning. We educate ourselves on our enemy. We read up on what he is capable of and look at ways we can overcome his attack.
As for the coaches, they are no neophytes. They have gone to the best schools, have attended continuing classes on learning and getting better at the fight game and are ready to help attain victory. You are then armed with an invincible attitude and with the “A Team” of coaches and trainers that makes up your medical team. You feel empowered to dominate and let no obstacles stand in your way.
What I describe is not an uncommon scenario with regard to a terminal illness. It’s not that an attitude of confidence or invincibility is bad or that having a world class medical doctor(s) and medical team behind you and encouraging you is insignificant. It’s just that if we solely espouse one philosophy or one ideology for the fight, it both helps and hurts us at the same time. I advocate the capacity of discernment to change our perspective depending on the reality of the fight. That is true wisdom.
One of the hospice nurses that I work with explains it this way: "I’m in the fighter’s corner watching the fight and it’s the 10th round. I see he is gasping, bleeding. He does not have the capacity to think anymore, he goes by instinct now having a hardwired program that guides him that originated all the way back at training camp that now is unable to be modified or shut off. He is possessed to fight to the end to whatever and whenever that end will be. His cornerman, his coach, persist in validating his conviction and energizes him to continue"
The hospice nurse empathically gives him another version of the fighter’s reality. She looks at him compassionately and empathically tells him that it’s ok to stop. He’s fought a great fight. He’s left nothing behind and gave his all. He executed the plan well and to the best of his ability. He fought bravely, let no one down and most importantly himself. He can leave the fight proud that he did everything he could.
The Sense of Obligation to Family Members
We expect our loved ones to fight. That is the unwritten rule. We just don’t give up.
That understanding initially bolsters our ability to engage with our care, to educate ourselves and go down a most difficult journey to become well again. People who care about you are immensely important. They support you on your bad days, advocate for you when you can’t, provide nourishment and feed you when you can’t do it yourself. They will do whatever they can in their power to keep you alive for it is unfathomably difficult to imagine life without you.
And you feel that and don’t want to let them down. You want yourself to exist and you want to not disrupt the family dynamic. You want to cater to them and let them know that you are doing your part in the plan, but you know it all too keenly, that at some point it all becomes an illusion/a fantasy that has become a burden more than support.
Few people are able to navigate that dynamic well for it’s just so difficult. Even fewer are able to do so during the time when hospice is not even part of the conversation. The more dire the situation, the more support and encouragement one gets from the family and very frequently the person who is going through the aggressive care feels like the victim without having the courage to say so to his family.
I know this as I’ve been privy to countless bedside conversations with my patients who find themselves in that scenario and when alone, when no family is around, they are able to confide in me their inner thoughts and sentiments about what they truly want. Those who are severely ill and not getting better at some point know that they are dying. They have reached that wisdom. They have become attuned to their reality. It’s just so difficult for them to let their family down.
Although not an exhaustive list, these are some of the reasons as to why we Americans strive to always fight even when we are faced with an unbeatable opponent. These observations are meant to make us think about our situation and how that information can help us navigate tough periods in our lives, especially when those times put us face to face with our mortality.
