Monday, November 21, 2011

End of Life ~Caring

Metaphysics of Decision Making

Oh no! OH NO! That little sparrow perched on that tiny branch visible outside the window, brushed by the sudden breeze, tumbled over. I mean TUMBLED and fell to the ground – lifeless.

Well, and this is a long pause - well. If I were to really dig deep, some bizarre thought configurations emerged for both the sparrow and what lay before me. For instance the conflicting emotions that ensued seemed to come from nowhere. Poof! They just burst onto my inner reality.

Maybe Maxwell’s little tiny demonic gate opened up in between my right and left brain and started pouring particles of thought, all the while picking and choosing trying to create that loophole in the second law of my thermodynamically heated brain. Although the linear flowing mathematical concepts (particles) must exist independently and remain segregated from the cool collective analytics of the nebulous and colorful right brain. Yep! sure. That damn Demon was up to some mischief. Not only was it messing with my thought flow, but it also seemed to understand neuro-trafficking, confusion states and how to manipulate them. And this was happening all in a moment when the sum-total of my energies was needed to focus on a life and death decision.

So now with this bottleneck of two independent and totally dissimilar concepts floating around in their Brownian dance within my brain, strange but quite evocative thoughts began to crystallize.

You know that saying, Uh huh, that very one, about security in the insecurity of life, that says imagine it, for there is no other. That one got under my skin. If I were to ascribe to the Copenhagen Interpretation of the Heisenberg’s Uncertainty Principle and the multiple potentialities or multi-verses or what have you, where the moment, I was going to commit to an action would change the future for this patient and mine by my doing – a heady thought but true, you would understand the pressures that come to bear on me as a  physician. 
Heisenberg's Uncertainty Principle Formula

Yes, you got that right! We are dealing with a human life here. You see, as I sat there with the patient chart in my hands, looking at the weakened body and the shallow movement of the chest and the diaphragmatic breathing of this once beautiful soul, the three universes began to emerge. Each distinct and different from the other and with the same present, each future exploded like a three-pronged projection, if you will, going forward.

Dimension #1

The first one; If I were to consider any interventional treatment there was a potential that she, the patient, would once again be able to understand her environment, maybe even speak full sentences without a cough, eat that bread pudding that remained untouched on her tray, smile or at least acknowledge another’s presence. But the statistics seem so oddly against such an eventuality. The odds were low, very low. On the fly statistics in my head gave that option less then 10% chance. Now where did that number come from? No data existed in any of the medical literature relating directly to this patient. 


So where? 


“No that is hardly scientific,” I thought. “What, then, have I fallen into the trap of masquerading as an elite scientist with facts and figures at the tips of my fingers.” 


That wasn’t the case either. But there it was 10% or less. Smack, dab stuck in the recesses of my brain. The number stared back within me, unmoving, frozen and recalcitrant, so I played with it a while, “How about 25% or 30%?” But no! It kind of just hung there, uncomfortably still. “Must be heeding to the Pauli’s Exclusion Principle or something.” I thought. 

You know that principle in physics that states, that two entities (fermions/bosons) cannot exist in the same place at the same time except with opposing spins. Well there was no spin here so other then the <10% no other number would fit, period. But <10% was still <10%. Life was life and in the best of times sometimes there are the worst of times. We have to make them better, don’t we? Should I subject this tortured vessel to more inhumanity for the sake of offering a delay to the inevitable given such horrible odds? The dilemma was absolutely shredding my already fragmented thinking.

Dimension #2 

And as easily as the first universe thought took a back seat, the second one opened and spread its wings too, This potential was to provide comfort and if her body gained the necessary momentum, then, and maybe then conceivably intervening with further treatment would be an option.

Really? and subjecting her to a similar delayed fate? 

Maybe not! or then again Maybe!

Even the use of a monoclonal antibody to help reduce the tumor burden was a possibility leading to maybe an extension of survival?  That universe had me thinking about her gradually gaining weight, wheeling herself around and then walking with a walker smiling as she went by. Her thinned hair fully grown again and her sallow cheeks filled with color.

“Heerre’s Johnny,” Ed McMohan’s voice suddenly came into my head from nowhere, introducing Johnny Carson.

“Jeez, What the…”

With the image of Johnny holding the closed envelope against his temple, 

“The Great Carnac says… nadda.” his voice echoed softly. 

Now how in the world did that thought arise at such a serious, solemn and contemplative juncture? That damn Maxwell and his demonic monkey must be throwing a wrench in it. “But 0% chance of that possibility?” I said out loud to my own surprise. I shook my head and looked up at the thin frame lying on the bed barely able to keep the virus of the soul contained within it. Yeah maybe The Great Carnac was right about this one after all. “Ok, shake it off!” I chided myself. The solemnity of the situation crowded all such frivolous mental expositions.

Dimension #3 

The third dimension seemed quite blissful and swept in with all the airiness of a summer breeze. To just provide comfort and allow the soul to depart quietly along with the dignity it had arrived in. However the soul departs and enters that undiscovered country, my job would be to let it with total serenity. I could imagine it. Suddenly my brain was awash with the clarity of purpose. The phase transition from the mathematical linearity of numbers to the nebulous grace of quiet certitude was complete and within it all the nuances of comfort, dignity and relief burst out within me.

Yes that is the right course of action. 

That was the right course of action.

It was peaceful, 

          the slow shallow breathing and then... 


There is special providence in 
the fall of a sparrow. If it be now, 'tis not to come; if it be not to
 come, it will be now; if it be not now, yet it will come—the
 readiness is all. Since no man, of aught he leaves, knows what is 
to leave betimes, let be ~ William Shakespeare

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