Doctors and nurses are the first to see the futility of strenuous intervention, but the fear of legal action can drive them into what is known as ‘defensive medicine’. This is bad medicine. The beleaguered doctors and nurses feel unable to make a decision based solely on professional judgement. They must always temper it with the thought that a decision or action might lead to an accusation of professional incompetence or neglect, or worse. Hospital practice today is driven by this necessity, and even if death is inevitable, doctors and nurses must be able to prove that they made every effort to prevent it. This is widely expected, nay demanded, by the general public and the law.
If people were with their elderly relatives all the time, day and night, as nurses are, they would be able to see for themselves the suffering and manifold indignities caused by the strenuous efforts to maintain life. Then perhaps they would be more inclined to say, ‘Enough is enough – and no more.’ Such a statement from a layman to a medical team is, I know, incredibly difficult. But the professions will usually accept it, and frequently with relief and gratitude.
Not infrequently an elaborate game of double-bluff is going on. Medical teams find it hard to suggest ‘no more, this is futile’ because they fear the reaction of relatives; at the same moment, relatives are perhaps thinking the same thing, but feel constrained from saying so in case someone thinks them callous or avaricious. No one will speak openly and truthfully. And whilst this is going on, a helpless old person at the end of life is unable to die.
Death, of course, will win in the end. But not the old-fashioned Angel of Death, nor even the dark Reaper, with the swish of his scythe. No, it will be the modern, hospitalised death, accompanied by the hum of a hydraulic airbed, and the bleeping of electronic monitors fixed to our fragile hearts and arteries, of flashing lights and drugs and drips and suction machines. All the paraphernalia of modern technology will guide us to our graves. We, who are growing old, cannot expect our children, and still less our grandchildren, to be with us at the hour of our death. We cannot, realistically, expect even a nurse to be with us. Machines do not need a nurse, unless the red light flashes on the central monitor, indicating that a drop in blood pressure or cardiac arrest has occurred, and then it is more likely to be a resuscitation team than a nurse that comes to watch and to wait.
I swear by the music of the expanding universe
and by the eloquence of the good in all of us
that I will excite the sick and the well
by the severity of my kindness
to a wholeness of purpose. I shall apply my knowledge,
curiosity ignorance and ability of listen.
I shall co-operate with wondering practitioners
in the arts and the sciences,
with all who care for people’s bodies and souls,
so that the whole person in relationship
shall be kept in view, their aspirations and their unease.
The secrets of the universal mind
I shall try to unravel to yield beauty and truth.
The fearful and sublime secrets told to me in confidence
I shall keep safe in my own heart.
I will not knowingly do harm to those in my care,
I will smile at them
and encourage them to attend to their dreams
and so hear the voices of their inner strangers.
If I keep to this oath I shall hope for the respect of my teachers,
and of those in my care and of the community,
and to be healed even as I am able to heal.
— David Hart
This poem was commissioned by the Observer newspaper to be a rewriting of the Hippocratic Oath, and was published there in July 1997. It was reprinted in Setting the Poem to Words (Five Seasons Press, 1998).
DR ELISABETH KUBLER-ROSS
(1926 - 2004)
Elisabeth Kubler was born in Switzerland, one of triplets, weighing only two pounds. No one expected the tiny baby to live, but from the start Elisabeth was a survivor. She fought for life, and survived to be the author of the seminal work On Death and Dying.
She was thirteen years old when the Nazi armies marched into Poland, ruthlessly crushing the unprepared Polish Army as they attempted to defend their homeland, then rounding up hundreds of thousands of Jews, forcing them into trains and then taking them to … well, at the time, no one knew where. Elisabeth was a young girl, listening to a scratchy old box-radio with her family, and she bristled with anger as she heard the news. She made a silent promise to God that, when she was old enough, she would go to Poland and help the people to defeat their cowardly oppressors. Her father and brother later witnessed Nazi machine gunners shooting a human river of Jewish refugees as they attempted to cross the Rhine from Germany to the safety of Switzerland. Few made it to the Swiss side. Most of them floated down the river - dead. These atrocities were too great and too numerous to be hidden from a young girl already inflamed by the outrages, and she renewed her promise to God.
Yet she didn’t really believe in Him. Not the God of the Lutheran pastor who taught and terrorised the Sunday School children, anyway. The pastor was a cold, brutish, ignorant man, unloving and unchristian, whose own children turned up at school with bruises all over their bodies, and were always hungry. The other children gave them food, but when the pastor found out he beat his children savagely for eating it. After that they didn’t dare accept. Elisabeth didn’t believe in the pastor’s God. Maybe there was another one somewhere who loved little children. That Lutheran pastor turned Elisabeth against organised religion for the rest of her life. But she never ceased searching for the God of Love in whom she could, and eventually did, believe.
From an early age she was determined to be a doctor, but her father would not allow further education for girls, so she left school at fourteen to become a maid. After a year of skivvying for a rich woman she ran away and arrived at a hospital, offering to do anything. In those chaotic war years she was taken on and told to work as an assistant on the VD wards, in which all the patients were dying. Syphilitic patients were feared, shunned and locked away, but Elisabeth found them to be pathetic creatures who were warm and pleasant, and simply craved friendship and understanding. She opened her heart to them, and it was this mutual affection that prepared her for worse that was to come.
On 6th June, 1944, the combined allied forces landed in Normandy and the war changed. Thousands of refugees from all over Europe streamed into Switzerland. For days, then weeks, they marched, limped, crawled or were carried. The very old, the very young - all were half starved, ragged and verminous. Virtually overnight, the hospital was inundated with these traumatised victims of war.
For weeks, Elisabeth worked entirely with children who were mostly orphans, frightened and lost. De-lousing and disinfecting them was the first job, then finding clothes, then the search for food. She and another girl stole most of the food from the hospital stores, which seemed like a good idea at the time, but nearly had serious consequences. She was saved from the wrath of the outraged authorities by a Jewish doctor, who quickly arranged for the Zürich Jewish community to refund the cost of the food. He proved to be a powerful influence on her young life. He was a Polish Jew, and he told Elisabeth the horrifying stories of the concentration camps that had been built in Poland, and of the need for dedicated young people to go to his sad country to help with rebuilding. His words were another clarion call to Elisabeth.