 Dr. David Shiedermeyer, who's a palliative care specialist with ThetaCare, palliative care in Nina, Wisconsin. You may say, what is he talking about on this session? But this session is really about surgeons and friends. And David was among the first fellows trained at the McLean Center in the 1980s. He is the author of Putting the Soul Back in Medicine, Reflections on Compassion and Ethics, Dr. Shiedermeyer is a community associate of the Medical Humanities Program at the Medical College of Wisconsin. And today he'll give a talk that is entitled, We Never Did Too Much Talking Anyway. David, welcome. Thank you so much. Well, it ain't no use turning on your light, babe. The light I never know. And it ain't no use turning on your light. I'm on the dark side of the road. I still wish there was something that you could do or say to make me change my mind and stay. Well, we never did too much talking anyway. You know, case one is wherein talking made him change his mind and stay. At the hospice, my patient, who's a dying man, was being asked to live a day longer. His son was coming in from Georgia and the hope was that he'd hold on. Hearing is the last thing to go, his daughter told me. We told Dad my brother was on the way. He wouldn't want to go without seeing his son first. He's a fighter. The nurse thinks he'll hold on and he won't die until his son visits. I don't know, I think, to myself. I think it's too late. He's leaving and he's on the dark side of the road already. I'm not sure there's something you could do or say to make him change his mind and stay. His pancreatic cancer is advanced. He has jaundice and puritis and a rock-hard liver. He has waxing and waning levels of consciousness. He has lung mets, aspiration pneumonia, a death rattle. I walked to the nurse's station and I'm right in the chart. Now no longer declining by the day but by the hour. Anticipate death quite soon. Symptoms being managed on acute inpatient hospice. I increased the dilaudid basal dose. I had a second scopolamine patch and I looked for a blank bereavement card back behind the desk. We do have one. I don't even bother to pull a fresh label for tomorrow's billing sheet. But I'm wrong. He does live till his son arrives. His family says he opened his eyes. He said a word or two. He squeezed his son's hand. There apparently was something they could do or say to make him change his mind and his body and stay. There apparently was a light that they could turn on. There apparently is a way for a person to control the timing of his or her own death. After working with dying patients for 40 years now, I'm quite sure I don't have the answer on this one. But I do have lots of clinical experience, lots of stories. I have seen people die too early, too late, right on time. I do think there is a unifying hypothesis even if there's not an answer. Because dying is a walk, it's a journey. Well, I'm walking down that long, lonesome road but I can't tell. Oh, you gotta walk. So when Woody Guthrie wrote these words and when Dylan wrote his words about walking that lonesome road being on the dark side of the road, they both captured the essence of the journey. It just makes sense that we can stop and pause a bit on a journey. We can't stay, we can't go back. Being human is the reason that we are traveling on. Our very mortality is the road that we're on. And Guthrie and Dylan sing about the loneliness of the journey, the uncertainty of the destination. It's a long and lonesome road. It's a lonesome valley. It's the dark side of the road. We're fundamentally alone in a bad physiologic place even if surrounded by faith, family. But if they call out to us, who's to say we cannot hear them? If I live life as a fighter, who is to say that all that training won't help me fight for one more day? If I was a beloved father, who's to say that I can't slow down the journey to hear my son's voice one more time? Who is to say that I can't fall down on my knees in the lonesome valley and grab this good earth with both hands for one more day? Case two, where in the dying look pretty good considering? In the hospital, the patient, a 90-year-old whose left middle cerebral artery bleed has left her aphasic and unable to swallow, is dying of electrolyte imbalances after about a week. She's had very little in terms of IV fluids. She's had good pain control. Her family has been supportive and thoughtful. They've been playing her favorite songs for the occur on various devices at the bedside. She has not been receiving any labs or tests. Her hands and feet are cold and the skin over her knees is modeled. She has a foley in and is making very little urine. As I visit, she's breathing deeply. Then she stops, then she breathes once more, then she stops completely. As she does this, her face begins to change, becoming, honestly, truly beautiful. All of us at the bedside, her family, a nurse who's happened to come in and myself, remark on how beautiful she looks and how peaceful her death was. Rooster crows at the break of dawn. This is another clinical mystery in my view since we always bear the marks of suffering on our faces and bodies. It's hard to die with a totally peaceful expression and without signs of a pretty rough struggle. I'm trying to say that death is rarely pretty. But in palliative care, our goal is to aim for a peaceful, mellow death. It's fantastic for everyone when a person can die with an angelic look on her face. What is it that causes these final moments to be so different aesthetically from person to person? Can we achieve a peaceful look as a standard of care with medications and symptom management? And what does it mean to be gone as the line of the song says, so quietly, so quickly, so freely at the break of dawn? Key elements in this case are that she was an elder, she was not overly hydrated, she'd not been poked and prodded during the dying process. Her cause of death was an overwhelming CNS process. Despite not being in obvious pain, she was on a low-level morphine drip. These are all good principles of palliative care. However, I've seen other patients with just the same disease, just the same configuration of medications, whose faces were not beautifully transformed at the time of death. Why was hers? And what if the opposite happens? What if a person takes a last breath and his or her face appears contorted by fear or pain or even terror? The reason I do care as a palliative care physician is that I want to be able to say she wasn't suffering. And a good facial look and body position at the time of death helps me to say this with the most obvious proofs right in front of us, that she was peaceful is a sort of final blessing. Did we ease her suffering? Yes, you can see it on her face. I will say that these deaths tend to have a flyaway appearance. Not only does the rooster crow, not only is the window open, but there seems to be the sound of angel wings. Perhaps there's an angel band, and if we can just get a glimpse before we go, we can make a face. A nice face. Son is singing fast, my strongest try. So we've looked at two issues. Can patients change the timetable of their own dying process? I'm arguing a qualified yes. Can we explain medically or even spiritually why some people have more peaceful looking in the last moments than others? A qualified no, despite the angel wing song. After all, it's not the look on their spirit, it's the look on their body that remains. We can't get that good look often enough. One last case remains. Case three, wherein we lament last words, last rights, last call for alcohol. The patient is a 90-year-old immigrant from Greece who never married. He has a massive sort of disability. It's not clear whether this was congenital or acquired, but it's caused him to have cognitive problems. However, he was able to have an active home life with his siblings, and he was able to play the mandolin. He has a massive MI. His EF is literally less than 10%, one of the lowest EFs I've ever seen. He literally, it seems to me, is a folks pattern or part function. I mean, when he makes the slightest movement in bed, he becomes so hypotensive that he looks like he's going to arrest. And then if he stops moving, his cardiac output improves just a bit. He prefers it just a little better, and he becomes alert. And then if he moves... Despite all this, it's with great difficulty that I obtain a DNR order and get permission for hospice. He insists that he be given nutritional supplements many times a day and be forced to eat. And here's the surgical part. They request a feeding tube placement, but I meet with him at the bedside with our surgeon. He refuses to place the tube and tells him quite simply he thinks the procedure will absolutely cause the patient's death. A wise surgeon. Despite obvious aspiration with each feeding, the family continues to force food. The man's last words are, I don't want to eat. Our hospice nurse is present at the time of his death and she has to stop the man's sister from trying to feed him even after he's dead. She says as kindly as she can, it's not time to feed him anymore. This last call for food and alcohol, so to speak, is something many family members try to do for their loved ones. It's tempting to show love by continuing to feed someone even when they're clearly dying. But can we learn anything from his last words? His response to all this fussing around him. Is there a more helpful ritual than trying to put food in a man's mouth at just the time that he's literally losing control of his airway? Mama ticked his badge off of me Can't use it, knockin' Knockin' on heaven I mean I think Dylan has it right again at the end of life instead of trying to put something in someone's body like food when they can't possibly use food for the journey. We should keep it on the tray. We should symbolically take their badges off. Their duties to us are fulfilled. Or if not, at least they can't do them anymore. They have no use for any of these things. We take our expectations, our guilt and shame, our dependence, our burdens, off them. Off comes the badge. Out comes the tube. The food is left on the tray, a symbol of our love. The extra beer is left open, untouched on the bar, and there they stay. The last call for food and alcohol is passed. We touch their hands but we don't hold on. We let go so they can use their hands next to knock on heaven's door or to help with the soft landing or to pull back the curtain or to turn over and really go to sleep. Well in conclusion after all these years and about these three cases I'd like to say this about dying. I don't recommend it. As these cases show we can avoid it maybe for a short time. We can try to make it aesthetically attractive but that is difficult and rarely accomplished. We can try to avoid burdening the dying. It does seem like the least that we can do. Your face was thin and you failed to shame I failed to let you down And for a few questions if anybody has any we still have two minutes left. I must say it's a pleasure being this group. I know I'm a bit of a ringer but this group is on time. Almost, right? Anybody questions or thoughts? I've got a question. Thank you so much. That was just beautiful and really speaks to me in my practice in palliative care. One thing that I think your conversation about dying with a peaceful look makes me think about is I think hospice and palliative care as a field have created this expectation that if we come along we'll make death perfect. I struggle with that and that you're conveying something else kind of a walking with or accompanying and a little bit of a mystery about what death is actually going to look like and I wonder how we can help our families understand that a little bit. Even ourselves. That's a great question. The expectation is if you have a palliative care consult the least they can do is get that good look. And of course what we're working against really is physiology. People have been pumped up in the ICU pumped full of vitamins, antibiotics and fluids and then we come in and also I think youth makes it a tough struggle to die. So many things are working against us to get that good look aren't they? What do you do? I want to change the conversation a little bit from making the death perfect to the fact that I will walk with them no matter what happens. I don't think we can get that perfect look and it is a mystery. It really does strike me as a mystery why some people are able to have that at the end and other people aren't. But I think death is hard. And I think we can't we are not the ones who can control that entirely. Now we try with our everything we do but we can't control the outcome in that way. We often use the metaphor. Thank you. We often use the metaphor of being born but I don't think babies look that great when they come out do you? Don't look that beautiful. Nurses do a great job. I talked to nurses about this a bit and they really buff up the dead person before the family comes but now that families are staying for the dying instead of leaving and coming back like they might have done years ago the nurses don't get a chance to go in and wipe the saliva off and get things looking better for the person. But that is still a big role that they do and I I appreciate that role. That's a pretty thankless job. Any other questions? Well, thanks for letting me talk. Thank you, Mike. Thank you very much.