Shift Issue #03: Integral Health and Healing • May 2004

An Integral Approach to the End of Life

Karen Wyatt | Shift | Shift Issue #03: Integral Health and Healing |

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During my medical career, through my experiences as a hospice medical director, I have spent a great deal of time reflecting upon death as it occurs in our modern society, pondering both the problems and the promises of this final, universal passage.

It occurs to me now, after experiencing much pain and loss in my own time, that life is a spiritual journey, for the purpose of teaching us certain truths and lessons as we travel through this physical realm. Our human bodies are sublime vehicles for gathering information and absorbing the wisdom of the universe: with five senses to experience the diversity of nature manifested through smells, sounds, sights, tastes, and textures; with limbs for mobility and action; organs for pleasure, performance, and sustenance; neurological linkages for learning, imagining, and reasoning; and systems for growth, repair, and healing. What an awesome gift this physical existence! And yet, it is a transitory gift at best. Soon enough, the faculties begin to fade and wear as we, ideally, exhaust the learning possibilities provided by this physical body.

So, a gradual shift in focus must naturally occur in the end days, from the gifts of the physical world to the truths of the spiritual realm.We practice letting go of the physical body and all its wonders in order to hone our spirits and perfect our souls for the journey that follows this one, whatever that may be. Dying, which is defined in Webster's Dictionary as "drawing to a close," is both a letting go of what was, and a preparation for what will be. The process of dying is meant to be an ending to a story, a final tying together of the threads of a tapestry to reveal a complete and perfect whole. Dying takes place in the present, where the finale, the finished design, reveals itself moment by moment, until the last breath is taken and the "mortal coil" is shed. The spirit is released to continue a journey into the unfathomable and inexplicable. While the loss of this beautiful physical existence is painful, it is, in my estimation, precisely the impermanence of this life that renders it precious. Knowing that it will come to an end requires us to savor each moment of sweetness and sorrow, and waste not one opportunity for learning or love.

I will never forget the sense of panic I felt, being responsible for my first "code,"

Though the dying process is universal and sacred, we live in a society to which death is an anathema, an enemy to be avoided at all costs. We have become a society that worships youth, fitness, and health at the expense of the many lessons that could be learned from pain and loss. Unfortunately, modern medicine plays a role in this massive denial of the true purpose of existence, with promises of new and better drugs and therapies, supporting the erroneous belief that no one should ever have to suffer. In a blind attempt to "help," modern medicine has unwittingly served to pave this detour from the true spiritual path of human existence.

What should we, as physicians, as healers of the physical body, contribute to this learning and growing process known as life, for the patients who seek us? How might we continue to utilize the masterful body of knowledge passed down to us by our forebears, and yet integrate it with an understanding of the spiritual realm which is so desperately needed in our society? The answers to these questions have become clear to me as I have pondered the lessons learned from dying patients. Consider the two stories that follow:

One of the first deaths I witnessed occurred during my internal medicine rotation as a first-year family practice resident. In fact, the patient died beneath my hands in the Critical Care Unit as we carried out a failed resuscitation attempt. I never knew the man's name or the details of his cardiac disease. I was the resident on call that night, and "running codes" was one of my assigned duties. He was referred to as "314-A," since in the urgent chaos of a "Code Blue" following cardiac arrest, location is a more pertinent designation than a given name. I will never forget the sense of panic I felt, being responsible for my first "code," or the shouting voices, the white noise from the cardiac monitor, the crush of too many bodies jammed into a tiny space, the rhythmic "whoosh" of the Ambu bag, the repetitive counting from one to five as I pushed my hands against his chest, the command to "Clear!," the "thud" of the defibrillator, the immediate seizing of the body, the resumption of sinus rhythm on the monitor.

But, particularly, I will never erase from my mind the expression on the face of the man in 314-A. Though he was supposedly unconscious, his eyes were wide with fear and his mouth twisted into a grimace. That aura of terror never left him. The nurse called his family to report his condition: comatose and not likely to survive another arrest. Would they like to come in and say their goodbyes? The family expressed two wishes that night: Do everything possible to save him, and don't call again until it's over. We, the members of the code team, felt sick at heart. Our orders were clear. We had no power to change this situation. We were all Mr 314-A had left to him in this world at that moment, but we could not change his destiny. He arrested four more times that night. On our final resuscitation attempt, his heart did not respond to the defibrillator jolt.

At last, we were able to allow this man some peace, though his body had long since given up the spirit responsible for its animation. I cringe even now to think of the nature of his closing thoughts, his last sensations, and his final moment of life, surrounded by well-meaning strangers who nonetheless inflicted a certain torture in the carrying out of their jobs.

Compassion and Dignity

Many years later, in fortunate contrast, I was able to share in the dying of Anna, a 93-year-old nurse with unstable angina and congestive heart failure. She had been admitted to our hospice service nine months before her death by a physician who had taken the time to ask her how she envisioned her last days of life. Because Anna requested that no aggressive measures be taken, that only palliative care be given, and particularly, that she be allowed to die in her own home, her physician, truly a compassionate healer, turned over her care to our hospice staff. Anna lived alone in an assisted-living facility, and though her family was very supportive and visited frequently, the days often grew long for her. When our team entered her life, weekly visits from our nurses quickly became a highlight for Anna as she delighted in sharing stories of her own days as a nurse, reminiscing and advising her young peers on the art of medicine. Her physical condition stabilized with such positive personal attention and caring relationships, a phenomenon that is frequently seen in hospice care. Our staff found it equally healing to spend time with Anna, as she provided homespun warmth and wisdom with each visit. Eventually, her condition did deteriorate as was expected, but Anna never saw an emergency room, a CCU, a cardiac monitor, or a defibrillator during her last days of life.

As she requested, she remained at home, sleeping upright in her favorite recliner, with various family members by her side providing care and administering her medication. I visited her apartment just hours before her death, and found Anna in her chair, holding her three-month old great-granddaughter in her arms. She grabbed my hand and pulled me close to her. "It's my time, doctor," she whispered. "I know," I responded, through tears that represented sadness for the loss that was approaching, but also awe at the beauty of the scene of her parting. Anna died that evening with grace and dignity, surrounded by the love that was a reflection of the way she had lived her life. I knew that night, as I whispered my last farewell for Anna to the heavens, there would never be another 314- A in my career. I could never again disavow the spiritual aspect of another human being while attending to the physical needs at hand. I was becoming, through hospice work and a certain amount of personal suffering, an integral physician without even realizing what that term meant.

"He placed a finger on my lips to silence me. Again pointing to the collage, he spoke, "Look! Even the worrying was perfect."

It is not surprising that this transformation occurred while I was working with dying patients, for medical care in the hospice setting is interdisciplinary or integral in its very approach, offered by a team of providers. Consisting of an MD, nurse, home health aide, chaplain, social worker, and volunteer, the hospice team meets the four quadrant needs of Ken Wilber's model of integral medicine. In addition, our hospice had, on occasion, brought in other support people to assist in specific needs of certain patients, including a rabbi, music therapist, psychologist, Native American shaman, and a Buddhist monk. Because the interdisciplinary hospice team meets weekly to discuss patient care, each team member has an opportunity to both teach and learn from the other participants. Such sharing of knowledge and insights is a powerful tool of growth and transformation for everyone involved.

Once, during my years of work in hospice, I had an amazing dream, or perhaps it was a vision, that has always stayed with me. I was led into a circular room that was filled with an incredible, resplendent light. In the center of the room stood an old white-haired man who was translucent and almost seemed to be composed of the light itself. He pointed to the wall of the room, which was covered with a collage of pictures. I saw that each picture was a scene from my life--representing both significant and trivial events, times of celebration and suffering, achievement, and failure. I observed that each scene had its own shape, and that all of the scenes fit together perfectly, as do the pieces of a jigsaw puzzle. Awestruck, I whispered, "It's all perfect. Everything that has happened has been perfect!" He nodded in agreement. I went on to bemoan, "Oh, if only I had realized this before. I regret all the time I wasted worrying about things and feeling despair. I just didn't . . ."He placed a finger on my lips to silence me. Again pointing to the collage, he spoke, "Look! Even the worrying was perfect."

Asking the Right Question

This dream became a new standard in my life, a challenge to view everything that happened as perfect. I would have an opportunity to use this new perspective some months later when I met Wanda, a retired nurse like Anna, but with a very different story. I was working in a nursing home where Wanda had been admitted after suffering a life-threatening illness from which she barely recovered. She was very angry that her physical condition forced her to give up her home and move into a nursing home, and she acted upon that anger at every opportunity. She would not get out of bed, instead lying there all day moaning, "Why me? Why me?"

The staff was exhausted, and had considered discharging her from the facility, when they asked me to see her and prescribe a sedative to keep her quiet. However, because I could no longer justify treating only a patient's behavior, I had to do some research to help me understand Wanda as a whole person, from all aspects of her being. I learned from her chart that she had been comatose while in the hospital, and had been expected to die on three separate occasions, but she had pulled through each time and survived her illness, only to find herself in this nursing home.

When I met her for the first time, she greeted me with her usual bitter litany of "Why me?" Without thinking about it first, I turned her words around and asked, "Why you?" This brought her whining to an immediate halt as she stared at me, shocked by my impudence. I went on to remind her that she nearly died three times while she was in the hospital, and yet had recovered. Why? For what purpose was she there in that nursing home at that particular time? Why was she still alive? What gap in her life history had been filled perfectly by the shape of this experience? Wanda turned her head away from me and refused to answer, while I silently kicked myself for speaking so impulsively. I decided to abandon the interaction and try again in two weeks when I was scheduled to return.

On that next visit to the nursing home, I found a very different Wanda. When I arrived she was thumping down the hall in a walker, fully dressed, hair neatly combed in place. "I know the answer to your question, doctor," she called out to me. Later she would tell me she had experienced a revelation: She was in that nursing home because the other patients needed her. With her background in nursing and patient care, she knew how to respond to people who are ill and suffering. She knew how to offer comfort.

Wanda began visiting other patients on a daily basis, particularly those who received little support from their families. She became such a valuable asset that the nursing-home administrator joked that he should be paying her to be there. Wanda had managed to turn what seemed to be a tragedy in her life into a blessing for others, as she figured out for herself the perfect purpose for her situation. She transcended loss to arrive at a new, higher plane of functioning. No drug, surgery, or therapy could have done that for her. She had to ask herself the right question, and she had to be willing to look deep inside for her answer. Could we wish anything more than this for our patients, or for ourselves? Could we be facilitators of this type of transformation for everyone around us, regardless of the state of their health?

If we choose to bring an integral awareness to the practice of medicine, whether we work with the dying or with those whose future death remains a mystery, we must find a way to ask ourselves the difficult questions and search the depths for our answers. To truly participate in integral medicine, we must open our own hearts to suffering and loss, to death in all its forms, to the perfection of this spiritual existence we have been asked to live out in physical bodies. We must see the collage of our lives, and understand that at some point, every piece, no matter how misshapen, will fit perfectly into that picture.

To practice medicine from an integral perspective is certainly no easy task, but it offers an opportunity to transcend the limits of reductionistic thinking and open to the possibility of true spiritual growth for ourselves. Once the first step is taken toward this larger view, there is no turning back. To become an integral practitioner is to reach, ever and unceasingly, like the tenacious tendrils of a budding seed, toward the transcendent, ineffable light.

KAREN WYATT, MD, received her medical training at the University of New Mexico School of Medicine and completed family practice residency at the University of Utah.