The following is a transcript of a lecture presented at MEDICAL GRAND ROUNDS, EVANSTON (IL) NORTHWESTERN HEALTHCARE, DECEMBER 12, 1997
If the Medical Grand Round series is somewhat like a medical journal, presenting a combination of the newest studies in diagnosis and treatment, summaries of the “state of the art” and so on, then this offering today will be a little different. For one, there won't be any slides. Today this will be more analogous to those other columns in The Annals of Internal Medicine or JAMA that go by the name of “On Being a Doctor” and “A Piece of My Mind” . These columns tend to bring a different point of view into the journal which stimulates thought and reflection on one's own experience as a physician. When I was a resident, I must confess, I never read these columns for I was only interested just in the “facts”, the hard stuff. Lately, though, I often find them compelling.
Before I get into the main ideas of this talk, I would like to bring your attention to the handouts which are, in part from the JAMA “A Piece of My Mind” column. These are copies of a series of articles by Dr. Roger Bone. Dr. Bone, as many of you know, was one of the preeminent scientist-physician-teachers of our time, a pulmonologist, intensivist, a researcher in ICU medicine, sepsis, editing and writing prolificly. My own book shelves are literally lined with the Mosby Yearbook of Medicine series, co-edited by him. Many of us have heard him give Grand Rounds here. In June of 1995, he was diagnosed with renal cell carcinoma, which was diagnosed as metastatic in October of 1995. He died on June 8, 1997, this year, at the age of 56. During this time he wrote a number of articles which were reflections on the practice of medicine and the end of life including a booklet on end of life issues for the American Kidney Society. These articles are enriched from his point of view of being a patient and inspired by the nearness of his own death. In a way, they are very analogous to the much more well known recent illness and death in Chicago of Cardinal Bernadin, for these are reflections of a people coming to grips with death and growing from it. In one of the JAMA pieces, Dr. Bone writes:
“I write this to record my last months of life. I write it for myself, for my family, and , I hope, for those many people in the future who might find comfort in it as they also face death, Three years ago, this could not have been written—at least not the way it is now. The reason is simple: Three years ago, I was not dying. But, even more than that, I had no idea what dying is all about, although I thought I had a fair understanding of death. I saw death more times than I can count. I always thought that death caused the collapse of the dying person inward upon himself. The dying person appeared to be little more than a shrunken shell lying in a hospital bed. Physical collapse meant that there was a collapse of the mental and spiritual being as well.
I know now I could not have been more wrong.
Death has opened my eyes to life - literally.”
I think you will find these articles very moving and they illustrate and express, more eloquently than I, some of the ideas that I want to discuss today, many of these ideas also informed by my own experience of being a patient.
Today then, I would like to talk about some spiritual aspects of life threatening illness and the practice of medicine. Take this as a “work in progress” without definite conclusions.
Every life threatening illness has both danger and opportunity within it. We know very well of the danger and are familiar with the fear associated with that danger. Most of our professional lives has to do with dealing with that danger, trying to properly diagnose, treat and manage it. Sometimes, though, with some patients, the “opportunity” part comes up. When it does, it is always striking, inspiring and gives true meaning to the clichs about clouds having silver linings, gold hidden in dark places.
As you may know, the Chinese word for crisis is composed of two pictographs - one for danger and one for opportunity. It is this latter part of the crisis of life threatening illness about which I want to speak: the opportunity for spiritual growth or spiritual unfolding. The real dangers and real fears of illness can defeat our souls or they can be a catalyst to the inner chemistry of the unfolding of the soul. And the soul, even in illness and death, can flourish and triumph.. In fact, I would propose that in the openness that life threatening illness can bring, we may be more open than at most other times in our life to receiving a spiritual teaching.
However, the subject of this talk is particularly challenging to me because, like so many professionals, I have internalized my own kind of “separation between church and state” , mostly keeping professional life and spiritual life separate. It is as if there has been within me and within my practice of medicine a boundary that is analogous to the kind of boundary we have had in western civilization for the past few hundred years between science and religion.
In a recent issue of Natural History Magazine, the evolutionary biologist and paleontologist Stephen Jay Gould has an article in which he argues that science and religion have eliminated much conflict by mutual recognition that each has teaching authority or professional expertise over non-overlapping domains: the empirical constitution of the universe is the professional expertise of science while the search for proper ethical values and the search for spiritual meaning is the domain of religion.
The net of science covers the empirical universe: what it is made of (fact) and why does it work this way (theory). The net of religion extends over questions of moral meaning and value and these two [domains] do not overlap…
To put it more simply, the turf has been divided. The scientists have the physical world, the material world and randomness as a basic (and useful) assumption. Questions of meaning and purpose are not considered to be scientific. In science, teleological questions, questions with a “Why” before them, are generally considered inferior questions. //00000112/#_ftn2> Religions have the turf of meaning and values. So if you want to know 'why', don't go to a scientist, go to a clergyman.
However, Gould goes on to say:
…these two [domains] bump right up against each another, interdigitating in wondrously complex ways along their joint border. Many of our deepest questions call upon aspects of both for different parts of a full answer - and the sorting of legitimate domains can become quite complex and difficult. Medical training and medical practice is mostly applied science. Whether it is physical, biological science or so called “behavioral science”, there is little training or even “official” recognition that human beings are not only physical and psychological beings, but even more so, spiritual beings. That would be a tough assertion to make on medical rounds: it is so vague and unverifiable, unquantifiable and we doctors are nothing if not eminently concrete and practical. Remember, most of the advances in medicine in this century come from the realm of science, and that has been what has been emphasized in our training. Think about modern antibiotic, vaccine, not to mention surgeries, organ transplants, kidney dialysis and so on, treatments, which we consider routine, that would have been considered miraculous in any other era in human history.
When we become ill, or suffer any kind of tragedy or sorrow, though, we often begin to ask in earnest, “why”. Science is very good at answering “how” questions: how infection with this bacteria or virus led to these symptoms or how high blood pressure and high cholesterol levels led to this coronary plaque and to this MI. If a person asks “why” to his physician, to one of us, and you listen very carefully to the physician's answer, you will hear disguised “how” answers most of the time. For the “why” answers you need to go to a clergyman, the chaplain, perhaps, or to a guru. But if they are honest with their explanations, they too will leave some open space, a space that correlates with the degree of inscrutability they attribute to God, the degree to which they have been affected by modernism, the degree to which they are comfortable “not knowing.” For “why” questions are questions of meaning and science has little to offer in this regard. However, with traditional religious “answers” regarding meaning open to question today, we most often need to discover meaning somewhere within us. Certainly others can help us and the wisdom carried by religions is available to us, but skepticism is also one of the cornerstones of the scientific mind and skepticism is part of the legacy of our age. So not only doesn't science give us the “why” answers, it tends to undermine the traditional “why” explanations of religion.
But we humans need to know why we suffer. It was Nietzche who said, “He who has a why to live for can suffer any how.” And, therefore, much of the spiritual work associated with illness is in this dimension delineated by “why”. It is in the realm of meaning and this realm of meaning is in an orthogonal dimension to the realm described by science.
So the subject of this talk does make me edgy.. But, it is at this “orthogonal” border where these two domains “bump right against each other” that I want to take us..
Do imagine for a moment that we are at this borderline, this “no man's land” between science and religion, the material and the spiritual, the secular and the sacred for life threatening illness very quickly brings us into this borderland.
In one of the articles you have, Dr Bone writes four “observations”, which, I would propose, come from his experience in this borderland:
1. Good health is often taken for granted; however, it is the most precious commodity one possesses.
2. One's spouse, children, family, and friends are the essential ingredients that allow one to endure an experience such a as a serious unexpected illness.
3. When faced with death, one recognizes the importance of God, and one's relationship to God.
4. The things that one does throughout one's life that seem so urgent are, most of the time, not so important.
For myself, this borderland became intensely real one summer afternoon when I found my way into the Emergency Room here at Evanston Hospital with chest pains, flat on my back and very rapidly, went from doctor to patient, and, almost, corpse in the course of about thirty minutes. All of a sudden, the doctor role dropped away and something much more essential was revealed. Something we all know, but can easily forget in our professional lives. It was that before we are doctors and patients, we are all people. We are all souls.
Therefore, one of the major themes that I want to raise for us to think about this morning, is that of boundaries and boundary crossing. It is not the boundaries between countries or states that I am addressing, but the boundaries we often draw between professional life and spiritual life, doctor and patient, illness and health, mind and body, psyche and spirit, even life and death. I, for one, have lived within fairly strict boundaries, trying to keep things neat and tidy. It doesn't always work. I doubt that it works very well for you either. I am not trying to say that boundaries don't serve a useful purpose: they do. If you are a physician, for example, and trying to maintain a reasonable family life, you have to draw boundaries somewhere. There are important boundaries one often needs to draw in caring or not caring for family members. So, this is not a challenge to all boundaries. But, to experience life-threatening illness, either as a patient, a family member, close friend or a professional is potentially to find ourselves crossing boundaries. It is to find ourselves crossing some boundaries we may have thought impermeable and others which we didn't even know were there.
For better or worse, we are living at a time when boundaries in all areas of life are seeming to be redrawn. This is certainly true in medicine, psychology and religion. For the most part, it can be an unsettling experience. And we resist. However, just as the boundaries between nations that we “see” on a map disappear when we look at the real thing, like the earth from space, many of the boundaries that we will be speaking of disappear when we look with a larger perspective. And, encountering a life-threatening illness can give that larger perspective.
In psychological terms, the close encounter with death makes us vulnerable and potentially more open than we may be at any other time. Familiar identity is challenged. One's self-image is no longer fixed. The ground upon which we stand moves like an earthquake and we can feel to be in a free fall. We no longer can take things for granted, but out of that chaos can come a new perspective. For the “taken for granted” is also often another way of being unconscious, another way of living in ignorance of the every day miracle we call “life”.
A patient dying of AIDS said:
“I didn't want this, and I hated this, and I was terrified of this. But it turns out that this illness has been my greatest gift. Now every moment is precious to me. All the people in my life are so precious to me. My whole life means so much more.”
In Greek mythology, Hermes, the Messenger of God, is the traditional god of boundaries and traffic over them. He is the guide of souls through this transitional space, for we never travel alone. Humans have always had guides through the ages, though we may understand them differently in different eras. Murray Stein, a Jungian analyst in Chicago, in a somewhat different context, says that Hermes “represents a type of consciousness that exists essentially within transitional time and space” … and he refers to this condition as “liminality”. Liminality refers to the Latin limen, meaning doorway or threshold. And it is the image of the door, along with that of boundaries, that I want us to imagine. In the experience of life threatening illness, we cross thresholds, enter doorways. We go from the familiar to the unfamiliar, from the known to the unknown. Not just patients, but doctors and nurses, too. Sometimes, it is quite literally a different place, like a hospital, but more so it is a different psychological space. And Hermes accompanies us though I do not mean this literally, but symbolically. We have deep, though often unconscious programming that is part of our endowment as humans. Call it the “collective unconscious,” as Jung called it, or “archetypal consciousness” as some of the transpersonal psychologists would call, or “Divine Aid,” as religions have called it, but we are not alone. For some this is concretized in the image of Jesus or Elohim or that of the Divine Mother. For others, it may Great Spirit or the Prophet. We are not alone. It has something to do with faith.
Another dying patient said:
“When you've come to the edge of all the Light you know, and you are about to step off into the Darkness of the Unknown, Faith is knowing one of two things will happen—there will be something solid to stand on or you will be taught how to fly.”
So illness brings us into a world of doors and boundaries and we are accompanied by some form of the “Messenger of God”, in our travels.
Once again, I need to back off a little in this domain.
I suppose that it is pretty weird for me as an internist to be talking about illness in this way during Medical Grand Rounds. For our whole training in medicine is mostly focused on disease processes, diagnosis, and treatment, pathophysiology. The physician-patient encounter is taught as one in which you get the “history”, whose purpose is to ferret out from the symptoms a pattern which is recognizable as a disease, and then do the “physical examination” and order laboratory tests. It is applied science. And, of course, we love it. But, many a patient finds it an unsatisfactory, incomplete experience, for there is a lot more going on in the patient role than just a conglomeration of symptoms. We all know that, but how do we address it, practically speaking? To relate only through scientific training seems to me to be limited. For in the face of life-threatening illness, there is a great hunger for spiritual attention. It is often a time when we are very open, but it is often unrecognized and unaddressed. We can just look at the list of best sellers by physicians Deepok Chopra, Bernie Siegel, Andrew Weil, Larry Dossey and Scott Peck, just to name a few, over the past few years to see some measure of that huge hunger. We can see it in the rise of alternate medicine, where people spend billions of dollars, most of it “out of pocket”, not covered by medical insurance.
So I think that though it may be weird to be speaking this way as an internist, when I cross any other boundary and see myself as a patient, or as just a human being, it is not. Indeed, this may be a cutting edge of medicine in the future, a counter movement to the industrialization process now underway called “managed care.” For managed care has helped us cut expenses but it does so by bringing in the same kinds of thinking that have been successful in other businesses and slowly, but surely it moves medicine more and more into the world of mass production and standardization. This is an impersonal world, and while it may have certain advantages, even in medicine, it is not likely to address spiritual needs. So, it brings with it a counter movement and this counter movement has spirituality at its core.
In doing a medline search for this talk, I came across a fascinating Presidential Valedictory Lecture given to the British Royal College of Psychiatrists in 1993 by Andrew Sims. Titled “'Psyche' - Spirit as well as Mind?”, he admonishes psychiatry for ignoring the spiritual experience of patients and goes on to say:
“The great taboo at the start of this century was sex, but it is now the last resort of the burnt out comedian. The unspeakable in the middle of the century was death, and now teaching about bereavement has even come back into undergraduate medical education. What is unmentionable at the end of the century is the personal experience of religious faith…. Yet spiritual concepts are, for many thoughout the world, a perfectly ordinary part of everyday existence.”
So it is in the spirit of breaking this taboo, in the spirit of crossing boundaries, and in the spirit of sharing that I want to tell you a story of a day when I crossed the line from doctor to patient. And it certainly seems appropriate to share this experience here.
The experience, which I would like to share, is that of a heart attack and cardiac arrest which was in August of 1995. It is an event, a date, that has a “before and after” quality to it, the way all life-threatening experiences have. A friend who has had stage 3 breast cancer and is surviving after the harrowing treatment that has included a bone marrow transplant, dates her “before and after” to the telephone call in which the surgeon told her biopsy results and prognosis. Sometimes it is a well-defined moment like that: an abnormal mammogram, a chest x - ray, blood in the stools, results of a blood test or an MRI scan. But it could be a pain, the swerve of the automobile, or the smell of smoke. In Dr. Bones's JAMA piece, “The Taste of Lemonade on a Summer Afternoon”, he starts out by describing his first symptom, the passing of blood in his urine on Christmas Day. Think about how many of these “before and after” events we as physicians participate in? Think how patients often describe them in a story-like way that can seem to have little relevance to us, as we abstract out the “facts” that we seek in the “history of present illness”. How routine they can become to us, how easily ignored. How conscious are we of the meaning, the significance to the patient of what we often so casually may say?
At other times the “before and after” is not so clearly related to an event but an inner realization. And though that realization is complex, it partly a realization that nothing is ever going to be the same again. It is also the realization: I am going to die. It may pass. The disease is cured, we may forget, deny, repress, whatever words seem appropriate. But, we are not the same anymore. From a spiritual point of view, we have been initiated into finiteness—into the human condition. Before, we knew we were going to die, but death was more of a concept than a reality. Now we know. There is a Zen saying that “In the face of real experience, concepts are like snowflakes falling on an open fire.”
All of this is true not only for the person who is ill, but also for all of those close to him or her. The effects of a life-threatening illness spread out like waves on water when a stone is thrown in. The closer we are to someone, the more profoundly we are touched by it and everything said just now applies. The whole family goes through these experiences: adults, children, even pets. Co-workers, acquaintances, patients, clients. The opportunity for the teachings of life-threatening illness to be received, extend to all of us. We don't necessarily need to experience everything first hand to learn from it. And we who work here in this hospital are also affected, much more than we may even be aware.
As I tell this story, I would like to try and tell it in a way that you actually are there. For, though it is my story, it is actually a story that occurs day in and day out, in this form or a somewhat different one. Therefore, it is a universal story as well. I am going to try and say it in second person, using “you” instead of “I”, though I might switch back and forth a little. But, the overall intent is for you to try and imagine yourself in this.
August 20 was a hot Sunday in Chicago. You were off that weekend, though there were some telephone calls from the emergency room and from patients in the morning. One was from a patient who was in Wisconsin, a few hours away, and who was having chest pains. She had been evaluated by your associate in the previous week and he didn't think it was anything serious but she was having them again and was frightened. So, after some discussion, you said that it was safe for her to drive back to Evanston and come to the emergency room. You spoke with the ER about her and another patient, who you had never seen but was the mother of one of your patients, and you agreed to care for her if she needed admission for what turned out to be a fractured pelvis. You were somewhat annoyed that all this activity had taken place on a rare day when you were “off” but it is hard for you to answer a telephone and say “no” or “I'm not here.”
I am in a three-person practice of internal medicine and the summers tend to be very busy, for the simple fact that it seems as if one of us is on vacation all the time so that you are covering each other's practice when you are not yourself on vacation. The preceding week was extremely stressful because of a tragic death of a friend' s son in Cincinnatti. He was 28 years old and died in the severe heat of an asthma attack. We had driven to Cincinnatti for the funeral and back in two days. It was very sad, emotional and physically taxing. In retrospect, you remember stopping at McDonald's on the way there and back and drinking thick chocolate shakes and eating French fries. In Cincinnatti, you had a uncharacteristic breakfast of fried eggs, hash browns and bacon or sausage. These are the kind of details you remember later, when you read more recent studies on coronary artery plaque instability.
Well, on this hot Sunday afternoon, you went to Lake Michigan, which is a few blocks from your home and read the Sunday Tribune and stood in the cool water. After about an hour you went into the Northwestern athletic center to work out, and though you felt rather washed out, you did a work out, of sorts, on a life cycle, a rowing machine, and using some weights. In the shower, though, you began to feel very weak and shaky and started sweating profusely. You began to feel pain in both your forearms. At this point, you got slowly dressed and walked upstairs to a vending machine to get a cranberry drink, thinking that you were experiencing a hypoglycemic reaction, remembering you had not had lunch. Your thoughts were very slow.
You bought the drink, sat down to drink it and the can felt extremely heavy. You could barely lift it. A sip didn't do any good. You started to think that something serious was going on, and even that you should call for help and get to the hospital. But, you were embarrassed by the thought of causing a big stir here, and also you couldn't really believe that anything that serious could be going on. You slowly walked out the building into the heat and you needed to sit down in front of it, when you saw one of the medical residents from the hospital coming in to exercise. You thought to call out to her to help but before you could say anything, she was gone into the building. It was steaming hot outside and your brain just said, “Get home.” You walked slowly to the car and drove home. All the while, pains were coming up from your arms into your chest. You passed Evanston Hospital, going down Central Street, thinking that you should turn in there, but when you passed it, you couldn't even imagine how to turn around and go inside. So you continued another few blocks to home, where you pulled in the driveway, left your gym bag in the car, walked in, lay down on the bed, and told your older son to call 911, that you were having chest pain.
The paramedics were there in a few moments and were giving you nitroglycerin and so on. They were calling in to the ER and talking about elevated ST segments. You can still remember some of your thoughts as you lie there, getting obvious relief from the nitroglycerin tablets under your tongue. But you were thinking that their field equipment wasn't that accurate and that they were overreading and making it more dramatic than it was.
Denial? Did I hear anyone out there think denial? Who me(?),—who knew every step of the way what was going on, but couldn't really accept it? At that time I just could not cross the boundary between health and illness, being “normal” and mortally ill. Part of me just couldn't do it. Granted, it lasted only 15 to 20 minutes, but denial is denial. How do we cope with such bad news? It is hard sometimes to see that everything is changed, and to adapt. How many older patients have we cared for who needed hospitalization but who, so irrationally, didn't want an ambulance to take them from their home? A few months ago, I was called to care for a patient in the ICU who was in a coma on a respirator, had gained 80 pounds of fluid in a few weeks in the effort to keep her blood pressure up, had bowel necrosis and raging infections, whose abdominal incision had shown not the slightest granulation one week post op, but whose daughter was still wondering about an infusion of massive doses of vitamin C the day before she finally accepted that her mother was going to die. My real job in this case was not to try and get this patient better—much more competent physicians and nurses than I had been working on that—but to work with her daughter's denial. I could now understand a little better her denial, that this (her mother's death) truly was unthinkable.
But when we let in the “unthinkable” is that not also an expansion of consciousness? Is that not what spiritual unfolding is all about? Is this not “growth” of the soul? Do we not have to expand our sense of acceptance, expand the heart, in order to grow from suffering, in general? (The spiritual heart. I am not talking about ventricular dilatation!)
You remember so vividly your youngest son, 11 years old, coming in the room—you know, the one who you are having difficult times with. And he says, “I love you, Dad”. Then you know you must look pretty bad. As you were wheeled outside to the ambulance, which seemed so RED in the sun, and driven to the ER, another boundary was crossed. You had been in this ER literally thousands of times over the past 13 years, but never had you seen it from this angle, flat on your back. You were now a patient and it is not so easy for a doctor, so used to being in control, to be flat on his back, a patient. You had a strange feeling, remembering being a baby, wheeled in a carriage. Perhaps, that was the last time you were wheeled in somewhere, feeling this helpless.
The first person you remember seeing in the ER was your patient from Wisconsin, who you sent there hours earlier with chest pain. You had forgotten about her. She looked at you in total amazement and in a few moments, her husband peeked into your stall to verify that indeed, it was you. You were no longer the doctor “in control”.
In the ER, you believed the doctors when they said you indeed did have ST elevations and were having an anterior myocardial infarction. The nitroglycerin did help and you loved them, looking forward to the next one. You are asked to rate the pain. This is one of those things that helps to understand how things are going. You are thinking, this is pretty bad, but my kidney stone was worse, so you gave it an “8”. You are now getting intravenous lopressor, aspirin and the heparin was getting started. One of the medical residents, who you knew well from supervising him for two years in clinic, and who is a very funny guy, tells you that he needs to do a rectal exam since they are starting heparin. You remind him to be sure and check the prostate at the same time. You shift into humor mode. Dave, the ER doc keeps asking you to rate the pain, and you think it got as low as a “4”. Time, though, time was getting very compressed in the intensity of everything.
In a few moments, you felt a little light-headed, but more than that, you heard a sound that sounded like cicadas. It was that high-pitched sound they make in the summer. You asked Dave what that sound was, and he said, with a voice tinged in anxiety and comfort, not to worry, for it was the sound people hear when they run lidocaine in quickly. Oh, you thought, lidocaine - you must be having an arrhythmia.
And that was your last earthly thought. Almost.
For in the next moment, you were transported to a different world, a different zone. It is difficult to describe, but it was both dark, black actually, but luminous. You know it can't be both but it was. There were three lights or figures that were like stars but were more figures than stars. It was extraordinarily quiet and peaceful. It was like every muscle relaxed and every care was removed. There was a sense of movement, going toward the figures, being carried in that direction. It is not easy to describe this. There was no sense of time. It was like waking up out of a sleep, and, like going to sleep when you take a nap in the daytime. It was very vivid.
And then, Dave, who is about 6 feet 4 inches and 220 pounds, is about six inches from your face, tears in his eyes, very emotional. He seems to be very excited, yelling, “Bob, we got you back. You were in V-fib!”
You remember looking at him, feeling very strange, thinking, is he all right? Then he said, “Did you see the white light?” Still feeling very calm and ironic, you said, “No, but I was going up the black tunnel.”
This all seemed slightly humorous at the time, even if it was a gallows-type humor. But, isn't that how we cope? I sure do. How many Friday afternoons have you signed out to one of your partners, your sides aching from laughing so hard at the sign out—this laughter a healthy substitute for the tears you would shed during the week if you weren't so emotionally controlled.
You lay there on the ER bed and it strikes you what has just happened, how close you just were to being gone forever and that it could happen any time again. The beach, the sunny afternoon, your home, your family—all seem so distant, so far away. A multitude of feelings from all the various reaches of your being come in. Conscious, unconscious, autonomic, primordial. Foremost was this feeling of wanting to live, feeling that it was not your time yet. You felt “in the middle of things”, not ending. You felt lonely. Would you ever see your wife and children and friends again? You began to decide what prayer to say, for after 22 years of daily spiritual practice, there were a lot of possibilities. Then, out of the depths from some unconscious place came, something you had never said before. It was simply: “If it be Thy Will, If it be Thy Will.” And with it came a sense not just of surrender, but of sacred submission. A feeling that you had never quite had before—at least like that. It was a total stripping away of the feeling of having any power or anything; but with it, came surrender and a feeling of peace. And this came up from some unknown depths, for on the surface was a big component of fear. Over and over again, silently, you said, “If it be Thy Will.” The difference between life and death at this point felt as slim as flicking a switch on and off. It was on now, but how long, and who held the switch was beyond me.
From there came the cardiologists and your partners and your spouse and we went into the cardiac cath lab which you saw from such a different angle. An angiogram diagnosed a totally occluded left anterior descending artery. It was amazingly quickly and efficiently done and an angioplasty guide wire was passed and the first balloon inflated. The pain came back.
Everyone thought this was great since it indicated viable myocardium. You asked how long one needed to keep the balloon inflated and learned an update of one of those basic life lessons: “Well, we've learned that the longer we can keep it inflated, the better the results.” “Okay,” you thought, “but just give me an idea of how long you're thinking.” “About 20 minutes.” It helps to know how long, but with so much at stake, they could have said three hours and you would have said fine. You felt total confidence in whatever they said. When the inflations were over and the pain stopped, an intra-aortic balloon pump was left in the aorta for the next two days. It was noticeable only if you paid attention to a kind of blip in the chest—a stronger heart beat.
The CCU nurses were like angels. Not ethereal angels, but kind of livesaving types. You began to feel things were going to work out. The angioplasty was successful in opening up the artery and even though there is another 90% lesion in a smaller obtuse marginal vessel, there was a general feeling of relief and of having passed through the worst as night came.
Later, after a few days, when things were settled, you asked for a book to be brought to the hospital which was Meister Eckhart's sermons. You needed to read the one he had written called “Blessed are the Poor”, which is an exegesis on “Blessed are the poor in spirit, for theirs is the Kingdom of Heaven.” It said it all. It was in “having nothing, knowing nothing, wanting nothing and being nothing” that we recognize the extent to which we live by God's grace. And while this could have been just good luck, or just good medical care, it had a different feeling to it as well—another dimension, orthogonal to the others, and it was that of being blessed by God's grace. Which, of course, despite our chronic complaining of how bad things are, is there, unrecognized, all the time.
Which brings us to the original title of this talk when it was given in St. Louis: “Dying to Live”. I thought it was kind of a catchy title because it has so many possible meanings. First, is in the sense when we say in a kind of slang exaggeration, like on a hot day, “I am dying for an ice cream.” , meaning “I really want ice cream” or “I really want to live”. And that is applicable here: “I was dying to live” - “We are all dying to live.”
But, dying to live also points to something else. It points to one of the basic universal, archetypal themes, and that is the theme of resurrection: out of death, comes new life. It is the ultimate religious theme, but it is a medical theme as well. Isn't that what surgery and general anesthesia is all about? In some sense we “die”, become unconscious, and, if all goes well, we are resurrected with a diseased part gone or a new hip.
But resurrection only comes after something dies. It comes after we have let go of something. After we have let go, first, of the way we thought things were supposed to be. We all have expectations, a kind of model in our minds of how life should go. My own experience is that much of this is unconscious but we become aware of it when things stop going our way, when the expectations are not met. And , we need to let go. Letting go of what we want, what we thought was going to be, and, instead, accepting what is.
So much easier to say than to do, and it is not a one-time thing, but a process. It is something that all health professionals help facilitate all the time, but it is not always a conscious process.
If we are, as many religious people would say, “spiritual beings on a human path,” having this experience of being human in order to learn what we need, then what we have been given, is what we need. I know this is a very hard thing to say, and I would never say it like this to someone else. But, I do try to apply it to myself and when I have seen others understand their suffering in this way, true resurrections occur—not always the physical resurrection that one would have really wanted, the cure, the remission, the restoration of function—but other things. We learn to let go of past grudges, forgive others, forgive ourselves, open ourselves, break out of the self - centeredness that has, unknowingly, trapped us and kept us disconnected in a deep sense. One of my favorite songs, by Leonard Cohen, has the chorus:
Ring the bells that still can ring Forget your perfect offering. There is a crack, a crack in everything. That's how the light gets in. That's how the light gets in.
To learn to love better, we need to let go of so much. The spiritual word for that is renouncement. Renouncement not as self-denial, but as a way of relating better; letting go of unnecessary baggage. Symbolically, renouncement is the opening of our grasping hand. [DEMONSTRATE] Reconciled to being finite, to having a limited lifespan, we connect ever stronger with the great flow that we are a part of. Call it the universe or God or history or nature. It is everywhere.
I want to read a section from journal which was written at Thanksgiving, 1995. It elaborates a little more on this theme of renouncement, a theme that is central to the spiritual path I have followed over the past 25 years.
“This morning, riding out to Glenbrook Hospital, I did a calculation. It is 95 days since my heart attack and cardiac arrest. I see this as a "second life”, one I almost did not have. This part of my life feels like a gift. It also gives life a “borrowed” quality. We are all living on “borrowed time”, though it is rare to think of it that way. Mostly we feel ownership of our time, of our lives. We own them. This is certainly better than to feel we are living as if someone else owned them. Too many people - perhaps most - have that experience. But, neither do we really own our lives either: we have been created. The first part of my life was a gift, too, but I never really saw it quite that way.
The spirit of renouncement is to realize one never truly owns anything. We are responsible for things, for our actions, thoughts and so on. We should be stewards, responsible caretakers, for the world's wealth. But possession is always temporary and this temporariness is easily mistaken for permanence. Can I give thanks with my life? In some very simple, deeper way, I understand (if that is even the right word) renouncement more clearly. We are born and die naked. In between, what matters are our connections, relationships with the Whole. The Whole includes all the parts, what theologians call the Immanent, what we might call “daily life”. The Whole is not something separate from the parts.“
On the one year anniversary of the heart attack, I worked out at Northwestern, the scene of it all beginning that day. After my run, for running has become my current discipline (surprise!), I showered in the same shower stall as I when I first experienced the sweating, the weakness and the arm and chest pains. Who should walk in but Tim, the cardiologist who did the angiogram and angioplasty that day. I briefly said hello and reminded him of the anniversary, which he acknowledged. Then, as I looked up at the clock, I saw it was 6 P.M., the exact time of that angioplasty, for I remember that the balloon was inflated for twenty minutes, beginning at 6 P.M. and that during this time all of the pain came back. I watched the clock from the cath table very carefully. The coincidence of this meeting in the shower, one year to the minute seemed and seems more than just a random coincidence. For me, it had the power of somehow proving the very existence of God. But, as a doctor, a scientist, how can you say such things, except in an ironic voice. Even now. It is as if that boundary between science and the spirit once again shows itself.
Earlier this year, the Chicago Tribune ran a piece by Saul Bellow, the Nobel prize winning author. In 1993 he suffered a life threatening illness which was a poisoning of his central nervous system with toxin that he contracted from bad fish in the Caribbean. He spent a month in the intensive care unit in Boston, with a very long recovery period. He shared his reflections at a medical conference in Chicago. Amongst other things, he said:
"In preparing my talk, I rejected at once the temptation to tell a convention of doctors how to conduct themselves with their patients. A team of doctors at Boston University hospital saved my life two years ago. Some of them seem to have taken my survival seriously, but I would sooner have them effective than compassionate. That is, if I were to have a choice…
No one can tell doctors what to do. … We can't possibly tell human beings, adults, to be caring, compassionate, sensitive; to interact, to enter into intimacies from therapeutic motives, et cetera.
No other person can value your life as you do. Nor should you demand or even expect such a valuation from anybody else….”
He describes in some detail how his senior neurologist was deeply involved with his recovery. The part that came after survival was no longer the issue. He says:
“The doctor's outlook—or if you prefer, his ideology—is humane, but his training is in science, and science does not see nature as having a soul. But the neurologist, Dr. X, did have a soul. He was capable of compassion, although in nature there is no compassion, so he came early in the morning and late at night and on the weekends.”
And as I work as a physician, I hear those words very clearly. Compassion is important, but only if it accompanies being effective. We still need to make the diagnosis, give the best treatment and often, assemble the best team of specialists and sub-specialists to help our patient. And there are many ways to go about it.
And so as we end, I think we are back to acknowledging boundaries, even as we acknowledge that we pass through them. At this point in time, I accept ambivalence and acknowledge that there are no easy answers, at least for me. For me, death remains the ultimate mystery or potentially the doorway to the ultimate mystery. But I do know the value and the truth of renouncement and the joy and necessity of living life to its fullest.
I want to leave with the following poem which I wrote during the few weeks off after this experience. It poses a challenge that I still feel, trying to live better in this “second chance” of a life.
The Loom Time passes and everything changes, But nothing changes very much. Four Ancient Women are weaving the Life-times, Here. The Loom is as big as a galaxy, The threads are invisible to us, but have Something to do With Cause and Effect. Threads, connecting threads between lives And deaths, Connections, relationships, synchronicities, But mostly, Unseen. We're too busy to notice, too much to do. Life is work or else, sleep or else unconsciousness. Is there another way? Can one get a glimmer of the threads now and again and live In the Weave?
Dr. Robert Magrisso is an internist in practice in Winnetka, Illinois, an Associate Medical Director for the Palliative Care Center of the North Shore, and on the staffs of Evanston Northwestern Healthcare and Northwestern University Medical School.