HawthoRNe and Palliative Care

Ok, I had no intention of watching a new television series (I already have way too many stored on the DVR). But after catching the first two minutes of the HawthoRNe episode "Yielding" in which they speak of discontinuing a patient's life support, I had to keep watching. I guess my curiosity got the better of me. Below is the first two minutes I was speaking of.

For those of you not familiar with this new TNT series, it centers around the Chief Nursing Officer, Christina Hawthorne (and the cleverly capitalized RN in the title is all TNT, not me), played by Jada Pinkett Smith. Hawthorne just lost her husband about a year ago and this series deals with her personal life as a new widow and now single mother along with her work as the CNO.

This episode focuses mostly on an elderly woman who has been on the ventilator now for 10 weeks and the hospital is feeling the pressure to get her extubated because they need the ICU bed. My first issue with this episode comes when they are speaking with the patient's son. They tell him that when there are no brain waves there is no chance for recovery. A correct statement but hmm... Is she brain dead?

The son asks for just 24 hours more to come to grips with things then he will take her off the life support himself(they offer to help him with it but he wants to do it himself). But the hospital needs the bed. So Hawthorne sets a storage room up to house the ventilated patient and thus give the son 24 hours more. A storage room complete with a shorting out power strip to plug the vent into. Again, hmm...

Meanwhile, a seemingly uncaring daughter enters the picture and demands the patient be taken off the life support right now as the patient had stated she did not want this. She goes to the cold hospital administrator type who demands the plug be pulled. (Is there an advanced directive? Or was it just a verbal thing? That was unclear to me.)

The biggest issue though was the very strange way of they had of removing "life support". They turn a dial and the patient's pulse and blood pressure drop (but you could still hear the vent going). Then they turn it again and the pulse and blood pressure drop further (vent sounds still present) and you hear the flatline. Hmm...

But even though Hawthorne wasn't able to grant the sons wish, it all ends ok. We find out later, the son had gotten a chance to come to the patient's room and say goodbye and the evil daughter cries when they told her her mother had died.

The title I started with for this post was "HawthoRNe and Palliative Extubation" but as I was writing I realized that they never say the word extubation and that is indeed not what they do. They say "remove life support" and "pull the plug" and it is all done with one dial. I do applaud the writers of Hawthorne trying to address end of life issues and the sentiment is there, but the attempt left me a bit confused. It seemed to be focused more on the stereotype of what people think "life support" is than any medical facts. I realize that the sentiment was really the whole point, but I couldn't get past the poorly done technical parts.

The episode had some other issues (nurse in hot pants doing drug inventory). The characters seemed stereotypical and the other plot lines were predictable. Some of the acting wasn't great. I think this may be the one and only time I watch HawthoRNe but I would be interested to hear what others, in and out of the medical field, think.

The Goodbye Boat

There is a vast amount of children's literature available about death. I wanted to review one such book I came across recently. It is a visually beautiful book, with sweeping oil paintings depicting the metaphor of death as leaving on a boat. The book "The Goodbye Boat" is by author Mary Joslin and is illustrated by Clarie St. Louis Little.

There are few words in this book, leaving the message to be portrayed visually. Two grandchildren are depicted with their grandmother. At first they are at play in summer by the beach. Then in the sunset a ship approaches. The grandmother waves goodbye and as the climate turns to winter the boat sails away. However as summer comes again the message is clear, with the children once again playing on the beach and happy.


The final phrase of the book, "yet when the boat is gone from view it's surely sailing somewhere new" is meant to provide hope after all of the sadness.

I like that this book gives its message in short words like "wondering", "weeping" and "lonely days". These phrases coupled with the moving pictures would surely help instigate conversations with children reading it.

In fact, in one of the reviews on amazon.com, I noted a reviewer said she read this book to her grandnieces after a death, and they asked to re-read it multiple times, each time asking new thoughtful questions about death.

I also like the various metaphors. The seasons that match the emotional responses is nice touch. The boat metaphor I like better than the "going to sleep" metaphor which can be confusing for young kids. However, this too can be confusing if the child assumes this as concrete fact. As one review pointed out, a child may assume the boat will come back... awaiting their loved ones return.

I also appreciated that the boat was seen approaching, long before the grandmother left on it. Although very much an ideal, it gives the sense that one can prepare and have a chance to say goodbye.

I think if I had to pick my favorite page of the book it would be this one below, with the words "wondering,". I encounter this feeling more often on a daily basis, doing palliative medicine work, than any of the other expected feelings of sadness, anger, etc. You can see the sad frustration and unknown in the expressions of the kids as well as the grandmother herself. Wondering is experienced by both patients and families, as well as with those of us in the medical world.












Joslin, Mary. "The Goodbye Boat" Eerdmans Books For Young Readers: Grand Rapids, Michigan. Copyright 1998

Eulogy

Eulogy is a 2004 comedy surrounding a "dysfunctional" family dealing with the death of the family patriarch. I've seen it described as a "black" or "dark" comedy. Probably fits.

The film begins with the family finding out about the death of Edmund Collins and then heading home to his funeral. Some members are upset over the death, some are upset about the inconvenient time. It is focused around the granddaughter Kate, a college freshman (and possibly the most normal person of the group) who has been asked to deliver the eulogy at her grandfather's funeral. Amongst the group of 4 children and 6 grandchildren, Kate seems to be the only one really concerned over Edmund's death. The rest of the family seems preoccupied with their old fights and issues.

Meanwhile, Charlotte, the widow, who is seemingly distraught over the death of her husband and her children feuding, attempts suicide. More than once.

During the course of the film, secrets come out about the surviving family members and about the departed. If I had to sum up the theme of the movie it would be, "We may be screwed up but in the end we're family." I'm not going to give away the end, but Kate finds a way to eulogize the grandfather who no one really ever completely knew. I like the funeral scene.

This film made me think a lot about dysfunctional families. It's not a term I use lightly. After seeing a lot of different types of families, I have begun to think that what we call "dysfunction" is often just functioning differently than the norm. What is normal anyway?

Gallery: "Afterlife"

Time again to pick a theme and look at some contemporary artwork that deals with it. Having just posted about digital afterlife, I began looking for current artists' material on the subject.

As with the topic of "pain" art, the idea of "afterlife" is very subjective. If anything, these works all have a bit of the surreal to them. As they should; unlike pain, none of us has been able to live through what comes after life and then document it from personal experience. These are works of the imagination, and so being, can be playful at times.

This first image entitled "Afterlife" is a mixed media piece by Donald McIntosh. There is a body on the left, separated from the complicated gears/machine like area on the right.


I came across an art site on the web that chooses themes for their artists to contribute to. They actually have an entire art pack dedicated to the theme "afterlife". The site is called Slashtree, and of those in the collection, I've picked out my two favorites to display. The first is the piece entitled "Afterlife" by Maciej Mizer. A link to the full image here shows how detailed this work is. A very imaginative creation with people, homes, castles, hot air balloons and even a McDonald's sign.



This next work from Slashtree, although not entitled "afterlife", asks the question behind the concept. The title of this work is "What will it be?" by Dominik. The subject in this work swings or dances, giving the viewer a sense that the answer to the question is at least playful and nothing to be scared of.



Finally, a bronze sculpture entitled "Afterlife Afterthought" (2005) by artist Emil Alzamora. This 8 foot structure to me depicts the out-of-body concept so many people speak about in near death experiences. Both images are of the same piece.

Just a small representation of contemporary works contemplating afterlife. In the future we'll look at some historical works of art with the same theme. As you can imagine the historical works have quite a different approach.

Seasons in the Sun

I came across this song while researching for the Top 10 List. Seasons in the Sun was a remake of the Belgian song by Jacques Brel "Le Moribund" or "The Dying Man". This better known English version was recorded by Terry Jacks in 1974.

I find it interesting that, while the English version was a remake, Jacks changes a lot of the meaning of the song.

Goodbye to you, my trusted friend.
We've known each other since we're nine or ten.
Together we climbed hills or trees.
Learned of love and ABC's,
skinned our hearts and skinned our knees.
Goodbye my friend, it's hard to die,
when all the birds are singing in the sky,
Now that the spring is in the air.
Pretty girls are everywhere.
When you see them I'll be there.
We had joy, we had fun, we had seasons in the sun.
But the hills that we climbed
were just seasons out of time.
Goodbye, Papa, please pray for me,
I was the black sheep of the family.
You tried to teach me right from wrong.
Too much wine and too much song,
wonder how I get along.
Goodbye, Papa, it's hard to die
when all the birds are singing in the sky,
Now that the spring is in the air.
Little children everywhere.
When you see them I'll be there.
We had joy, we had fun, we had seasons in the sun.
But the wine and the song,
like the seasons, all have gone.
Goodbye, Michelle, my little one.
You gave me love and helped me find the sun.
And every time that I was down
you would always come around
and get my feet back on the ground.
Goodbye, Michelle, it's hard to die
when all the bird are singing in the sky,
Now that the spring is in the air.
With the flowers ev'rywhere.
I whish that we could both be there.
We had joy, we had fun, we had seasons in the sun.
But the stars we could reach
were just starfishs on the beach



Now compare those words to that of the original. (Sorry not the best video but it has English subtitles, which, as I speak no French, I found very helpful.)

In the French version of this song, it was meant to be understood that this was a man about to commit suicide (although he doesn't quite come out and say it). In Jacks version, he could have been dying of anything. Jacks also takes out the infidelity that plays a huge part in the French version.

I think Jacks takes all of the bite out of the song. When I first read the words to Le Moribund, I thought it seemed like a suicide note. The singer is saying goodbye to some of the people in his life and seems to be almost blaming others. Seasons in the Sun didn't seem like this at all. Just a man saying goodbye. Not nearly so dark.

Digital afterlife

Digital technology is changing just about everything we do, including death.

It used to be more simple. One died, then according to one's will, family took possession of what remained and kept or destroyed journals and pictures accordingly. Obituaries were in the local newspaper and sympathy cards were mailed. The digital world has altered it all and created many new legal questions that are yet to be resolved.

For one, what happens to all your email and online accounts? Unless specified in your will then it really depends. If family members know your passwords, they may be able to sift through and even keep things like your facebook page and twitter accounts "alive" after you are gone. In fact, some use these accounts as a place for virtual mourning. People can post condolences on facebook pages, post pictures in remembrance, etc. A digital memorial may ensue.

Here's an example of a facebook memorial. This example is of a specific memorial created as a group after this person died. People join and leave comments of condolence. The other way memorials are created are when people leave messages on the deceased profile page. What many find different in the way of typical condolences is that people then address the deceased personally. These few examples are from an 18 year old girl who died in March of this year in Colorado Springs:

"I hope alls well up there. we're gonna miss you an awful lot down here."
"I walked into church today and thought I saw you walking across the foyer. Just so you know, there's a girl that looks so much like you it's insane."
"hey girl hey. so this morning I had the horror (or pleasure?) of waking up to a giant bushy squirrel. ... obviously I thought of you and our mutual squirrel obsession."

If this makes you a bit squeamish with uncertainty, there are new companies out now to help sort through the thorny issues of digital afterlife.

Legacy Locker was created this year as a "safe and secure way to pass your online accounts to your friends and loved ones". For a small fee you can assign what you want done with your digital property. You can store passwords to favorite accounts and designate what you want done with these after you die.

As for digital memorials, well known site Legacy.com has a large market. For a small fee, you can create a digital legacy, with photos and video, a link to the paper obituary and even a guest book for friends to sign. Of course, to keep it up and online, you must continue to pay a fee each year. The site has some online current examples here.

Mylastemail.com has combined the ideas of legacy locker with legacy.com by allowing the person themselves to pre-design their own memorial. They offer a way to store financial and legal papers on line, as well as upload photos and videos. You get to write your own story and then you choose who gets invited to open this lock box of goodies after you die. With this service, once you die, no one can change what you've already uploaded and designed. The site guarantees staying in existence at least 25 years after you die.

One thing is certain, this is just the beginning. If you thought the term "digital afterlife" was a novelty, just wait a few years and see where things are!

Top 10 Contemporary Palliative Care Songs

Happy Anniversary to Pallimed: Arts & Humanities. And happy Memorial Day.

To commemorate our one year anniversary, we decided to make another Top 10 List. If you all remember, we started out with Top 10 Palliative Care Films back on May 17th 2008 (ok, we're a few days late). As with the other list, the Top 10 Contemporary Palliative Care Songs is a lot of personal preference, but we did try to get in songs from many different genres. Also, we interpreted "contemporary" very loosely. Mostly it means in the past 50 years. We know that there are alot of good classical songs with palliative themes (we have blogged about some), but we wanted to exclude them from the list for now.

The links will take you to YouTube videos for most of the songs.

10. Happy Phantom-Tory Amos

9. Girlfriend in a Coma- The Smiths

8. One More Day-Diamond Rio

7. I Will Follow You Into the Dark-Death Cab for Cutie

6. Until It Sleeps-Metallica

5. Another One Bites the Dust-Queen

4. Meet You There- Simple Plan

3. Tears in Heaven-Eric Clapton

2. Casimir Pulaski Day-Sufjan Stevens

1. What Sarah Said-Death Cab for Cutie

Please share your favorite palliative care songs in the comments section.

Edgar Allan Poe

A happy belated 200th birthday to Edgar Allan Poe. (An event with brought out some controversy over which city can call itself Poe's hometown: Boston, Baltimore, Richmond, New York, or Philadelphia. There has also been talk of which city has claim on Poe's remains.)

Poe was born in Boston, January 19, 1809. I think we all know Poe for his horror writings, but he is also contributed greatly to the science fiction genre and is considered a founder of the detective-fiction genre.

To say Poe had loss in his life is an understatement. Both of Poe's parents died before he turned three. He was taken in by a wealthy merchant family, but the relationship with his foster father was often a rocky one and eventually Poe was disowned. His beloved foster mother and older brother both died when Poe was in his early 20's.

At age 27, he married his 13 year old first cousin, Virginia Clemm. Several years later, she became ill with tuberculosis. Around that time, Poe began to drink more. It's thought that his wife's illness was the inspiration for one of his most famous poems, The Raven. Virginia eventually died. The recurrent theme of dying young women (Annabel Lee, Lenore)in his work has been contributed to Virginia's illness and death and to the death's of other women (mother, foster mother) in his life.

After Virginia's death, Poe became very unstable. Two years later, he was found wandering delirious through the streets of Baltimore. He died soon after and the exact cause of his delirium and death has remained a mystery. He was buried in an unmarked grave in Baltimore but his remains were later moved.

Since 1949, the Poe Toaster (an unknown gentleman dressed in black) has been visiting the grave marker of Edgar Allan Poe's original burial site each year on his birthday. He toasts Poe and leaves behind a half bottle of cognac and three red roses.

I'll close with my favorite Edgar Allan Poe poem, Eldorado. (I don't know what that says about me. A sucker for hopeless causes?)

                Gaily bedight,
            A gallant knight,
        In sunshine and in shadow,
            Had journeyed long,
            Singing a song,
        In search of Eldorado.

            But he grew old-
            This knight so bold-
        And o'er his heart a shadow
            Fell as he found
            No spot of ground
        That looked like Eldorado.

            And, as his strength
            Failed him at length,
        He met a pilgrim shadow-
            "Shadow," said he,
            "Where can it be-
        This land of Eldorado?"

            "Over the Mountains
            Of the Moon,
        Down the Valley of the Shadow,
            Ride, boldly ride,"
            The shade replied-
        "If you seek for Eldorado!"

The Antlers: Hospice

This self-released, indie rock/ambient album's title should grab the palliative medicine community. Peter Silberman spent a year in isolation from friends, then another year to write about his experience in this album that was released March 3rd, 2009.

The tone of the album is dark and dream-like. Silberman creates a symbolic figure named Sylvia...taking inspiration from the macabre world of Sylvia Plath, as well as a fictional Sylvia depicted in the novel "Sylvia" by Leonard Michaels. Both Sylvias have tragic lives, burdened by degrees of mental illness, depression and death. Perhaps it is their illness coupled with their tortured relationships that allows Silberman to draw inspiration... regardless "Hospice" dwells on the ending of a claustrophobic relationship by portraying death, nightmares and illness.

The only clue to the title comes from Silberman's blog of the album's process. He leaves a post with the definition"hospice n 2: a program of medical and emotional care for the terminally
ill".

In the song "Kettering or, bedside manner" we encounter a woman dying of cancer (Memorial Sloan Kettering Cancer Center) and a hired caregiver. The song, in medical terms, has a crescendo/decrescendo flow. It swells, peaks in sound and settles again. You can listen to the song at the artist's myspace page here. The lyrics are as follows:

I wish that I had known in that first minute we met, the unpayable debt that I owed you. Because you'd been abused by the bone that refused you, and you hired me to make up for that. Walking in that room when you had tubes in your arms, those singing morphine alarms out of tune kept you sleeping and even, and I didn't believe them when they called you a hurricane thunderclap.

When I was checking vitals I suggested a smile. You didn't talk for awhile, you were freezing. You said you hated my tone, it made you feel so alone, and so you told me I ought to be leaving. But something kept me standing by that hospital bed. I should have quit, but instead I took care of you. You made me sleep and uneven, and I didn't believe them when they told me that there was no saving you.

The album is definitely dark, with lyrics about waking up in a morgue and being buried alive in "Epilogue". And from "Shiva" the opening line is "Suddenly every machine stopped at once, and the monitors beeped the last time. Hundreds and thousands of hospital beds, and all of them empty but mind." You can read all the lyrics to the album here.

Although just released, the album is getting a lot of press. In fact NPR's All Songs Considered has named "Hospice" as the best album of 2009, so far.

So take a listen and let us know what you think.

The Shootist

Thanks to one of my nurses, Linda, for telling me about this film. Westerns aren't my usual movie fare but hearing about the plot of this one along with the all-star cast (John Wayne, Jimmy Stewart, Lauren Bacall, Ron Howard, Harry Morgan) convinced me to check it out.

John Wayne plays JB Books, an aging gunfighter, who comes to Carson City seeking a second medical opinion. He has gotten the diagnosis of cancer and comes to see a trusted physician, Doc Hostetler (played by Jimmy Stewart). In one of my favorite scenes, Books is told the bad news and is given about 2 months to live. (I couldn't find a clip, but below is the dialogue.)

Doc:Books, every few days I have to tell a man or a woman something I don't want to. I've been practicing medicine for 29 years and I still don't know how to do it well.
Books: Why don't you just say it flat out?
Doc: Alright, you have a cancer. Advanced. [portion removed]
Books: Can't you cut it out doc?
Doc: I'd have to gut you like a fish.
Books: Well, what can you do?
Doc:There's just very little I can do. When the pain gets too bad I can give you something.
Books: But you're trying to tell me is...
Doc:Yeah
Books: Damn
Doc: I'm sorry Books.
Books: You told me I was strong as an ox.
Doc: Well even an ox dies.
Books: How much time do I have?
Doc: 2 months, 6 weeks, less. There's no way to tell.
Books: What can I... What will I be able to do?
Doc: Anything you want at first. Then later on you won't want to.
Books: How much later?
Doc: You'll know when.

In another conversation with the doctor, Books asks about how it is going to go. Doc Hostetler tries to evade the question at first but then tells him "There'll be an increase in the severity of the pain in your lower spine, your hips, your groin. Do you want me to go on? The pain will become unbearable. No drug will moderate it. If you're lucky you'll loose consciousness and until then you'll scream." He goes on to tell Books, "I would not die a death like I just described... Not if I had your courage." This leads Books to try to go out in a blaze of glory. Hastened death by gun fight.

Much of the film is Books coming to grips with his terminal illness, fighting off those who want to take advantage of his death, settling his affairs, and imparting words of wisdom to a young man, Gillom (Ron Howard). Below is the film trailer.

This movie came out in 1976 and it was John Wayne's last film. It came out 12 years after he was diagnosed with lung cancer and 3 years before he died of gastric cancer. In many ways, the lives of Books and Wayne are very similar. Both very famous, facing illness and the end of their careers.

Also, Lauren Bacall (who stars as a sort of platonic leading lady in the film) had lost her husband, Humphrey Bogart, to esophageal cancer many years earlier. I wonder how this effected her performance in the film.

Something interesting from a historical palliative care perspective, they use laudanum (opium mixed with alcohol) for pain control. When Books takes a swig out of the bottle, the question is asked, "That's habit forming, isn't it?" Some things are timeless.

Francisco Goya

Francisco Goya (1746-1828) was one of Spain's greatest artists and his works have become a chronicle of Spanish history. By painting the aristocrats' idyllic lives in portraits, his paintings serve as a visual account of this important time in Spain's past.

In 1792 however, at the height of his career, Goya contracted cholera with subsequent sequelae of paralysis, partial blindness, vertigo, tinnitus and eventual deafness. Gone were his colorful happy portraits, and what followed were new dark and macabre paintings.

We can get a glimpse, possibly, into his psyche with his etching "?De que mal morira?" ("Of what illness will he die?") (1796-97). The physician depicted as a donkey in a suit may be how Goya viewed the medical community at the time. In the background we see the hooded figures waiting for this gentleman's death, while the physician can do nothing but take the man's pulse.

Although Goya survived his illness, he was left permanently altered. Many believe he suffered an encephalopathy of sorts from the high fevers during his earlier illness causing a degree of madness. Most indicative of this dark period are the "Black Paintings", done at the age of 74, they are a series of 14 works done in fresco style on the walls of his house.

The very method of painting on your own walls, implies a privateness to the pictures. They weren't painted to be viewed by anyone but the artist himself, as a kind of visual diary to the thoughts and images he was experiencing in his older age.

In this series is "Two Old People Eating"(1820), these 2 men both pointing at who knows what, could have been Goya's only companions for his meals. The figure on the right is almost skeletal, and both seem to be taunting the artist.

These next two pictures in the Black Paintings collection framed one of the doors downstairs, with "Two Old Men"(1820) on the left and "A Manola"(1820) on the right. Here we see the possibility of Goya as an old man with the call of death being whispered in his ear. Whereas in the next scene the manola is in mourning clothes, resting on a grave- maybe Goya's? It says much to know Goya painted these on a doorway to which he was forever walking through. Perhaps reminding himself daily of his own mortality.


Providing yet another glimpse into his world, Goya left us with "Self-portrait with Dr. Arrietta" (1820). Once again a commentary on the physician-patient relationship, this time the doctor offers compassion with his embrace and cup of kindness to the artist himself. The haunting figures are still present, but the doctor acts as a barrier of protection. The painting is inscribed on the bottom with "Goya in gratitude to his friend Arrieta for the skill and care with which he saved his life in his acute and dangerous illness suffered..."

Illness abruptly changed the nature of Goya's paintings, just as terminal illness changes the reality of our patients' lives. What images would we see depicted if our patients' narratives could be portrayed, like Goya, in works of art?

For a look at more Goya paintings see the Black Paintings and a large collection at Olga's Gallery.

Until It Sleeps

Image by Getty Images via Daylife

Metallica has been in the press a lot lately. They were inducted into the Rock and Roll Hall of Fame on April 4th. Also, this Spring, Guitar Hero Metallica was released. We tend to post more on the music genres we are familiar with, but with all this attention, I'm going to delve into the world of thrash metal. Really, I just wanted to add "Metal" to our label cloud.

So what does a thrash metal ("an extreme subgenre of heavy metal that is characterized by its fast tempo and aggression") band have to do with palliative care? It was recently pointed out to me (by my husband) that Metallica's lyrics are often based on their life experiences. In fact, Metallica vocalist James Hetfield once said "All our songs deal with my youth in various ways." "Until it Sleeps" was written by Hetfield and Metallica drummer, Lars Ulrich based on Hetfield's experiences and losses.

Hetfield was raised as a Christian Scientist. When he was 16, his mother (a devout Christian Scientist who is said to not have believed in or sought traditional medical treatments) died from cancer. Her death is also said to have been the inspiration behind the songs "The God That Failed" and "Leper Messiah" (obviously a recurring theme!). Many years later, his father also died from cancer. Per music lore, Until It Sleeps was written about cancer.

The song starts " Where do I take this pain of mine, I run but it stays right by my side". He goes on to describe something inside that "grips", "stains", "hates". Something that needs to be torn out and washed away. At first, I interpreted this as being the cancer. But could it be the pain and loss caused by the cancer? Sort of a way of showing the similarities between the two (the physical form of the cancer eating away at the body and the emotional pain eating away at soul). Why does he say "And the hate still shames me"?

The video is inspired by the Renaissance painting, The Garden of Earthly Delights, (particularly the third panel of the painting representing hell) by Hieronymus Bosch (Wikipedia link has a great close up of the painting when you click on it) and other works of art that depict the fall of man. There is a lot of religious imagery which could represent some of Hetfield's own struggles with religion. A word of warning: This is a heavy metal video and some of the imagery is disturbing. These images do not represent the views or opinions of Pallimed or any of it's writers. Note prominent the fall-of-man themes throughout.


Where do I take this pain of mine
I run but it stays right by my side
So tear me open and pour me out
There's things inside that scream and shout
And the pain still hates me
So hold me until it sleeps
Just like the curse, just like the stray
You feed it once and now it stays
Now it stays
So tear me open but beware
There's things inside without a care
And the dirt still stains me
So wash me until I'm clean
It grips you so hold me
It stains you so hold me
It hates you so hold me
It holds you so hold me
Until it sleeps
So tell me why you've chosen me
Don't want your grip, don't want your greed
Don't want it
I'll tear me open make you gone
No more can you hurt anyone
And the fear still shakes me
So hold me, until it sleeps
It grips you so hold me
It stains you so hold me
It hates you so hold me
It holds you, holds you, holds you until it sleeps
AND IT WONT IT WONT IT WONT IT WONT IT WONT IT KNOWS
So tear me open but beware
There's things inside without a care
And the dirt still stains me
So wash me 'til I'm clean
I'll tear me open make you gone
No longer will you hurt anyone
And the hate still SHAMES me
So hold me until it sleeps

Franz Schubert "Death and the Maiden"

Franz Schubert was a gifted composer who died tragically young. Easily considered among the "greats" of composers, Schubert contracted syphilis in 1822 at the age of 25. He continued to compose, even as his health deteriorated. Many say that the works of his last 2 years became very dark, showing a deeper sense of spiritual awareness, and even a sense of the "beyond".

At the age of 20, Schubert put to music a poem by Matthias Claudius entitled "Death and the Maiden". The lied portrays a maiden begging for death to pass her by, and Death trying to persuade. The words from his song and Claudius's poem are as follows:

Maiden:
Stay away! Oh, stay away!
Go, fierce Death!
I am still young, please go!
And do not touch me.

Death:
Give me your hand, you beautiful and tender vision!
I am a friend, and come not to hurt you.
Be of good cheer! I am not cruel,
You will sleep softly in my arms!

This theme of Death and the Maiden is seen in art as well as music. Usually death is portrayed seducing or tempting a beautiful maiden. The idea that death would be a temptation began earlier in the 1400's when death was portrayed in the Dance Macbre, playing an instrument, luring people to death. Perhaps if Death was a temptation, then humankind could avoid the temptation, and avoid death? Death and the Maiden as a theme also conjures up a feeling of vulnerability in youth, as well as beauty. It leaves us with the feeling that life is fleeting, as beauty can be.

Schubert did an interesting thing. In 1824, a few years after his syphilis diagnosis, as his own mortality became central to himself, he re-worked his original Death and the Maiden lied into a string quartet. The theme, while similar to the original lied, takes on a very agonized and at times urgent tone. We might surmise the urgency he himself felt as he became more ill.

Listen first to the earlier lied by Schubert. This video from YouTube of Marian Anderson singing has a classic Death and the Maiden art image shown in the middle. (For email readers click on the post's title for re-direction to the original to see the video)

Second, here are two short videos I've done from the later string quartet. You'll notice the words from the original lied placed in the video, as well as suggestions to what you're hearing. The first is the maiden and the second Death answering. Hopefully you'll appreciate the dramatic difference in the earlier lied and later quartet and notice that the theme of "Death and the Maiden" took a very personal turn for Schubert.







A few short years later Schubert did die. He was only 31. It is believed he died from complications for syphilis, though some believe he may have died from mercury poisoning, which at the time was the standard treatment for syphilis.

Goodbye ER

ER premiered Sept 19, 1994 and was the creation of the late Michael Crichton. (Crichton wrote the screenplay for ER based on his experiences as a resident.) On Thursday, April 2nd, after a 15 year run, the series finale aired on NBC, entitled "And in the End..."

I haven't watched ER in many years. I stopped watching shortly after I started medical school because I just couldn't take the medical drama anymore. But I just couldn't help myself from tuning into the finale. When I watched ER in the past, it was not from the perspective of a palliative care doctor. I was pleasantly surprised Thursday to find several palliative care themed plot lines.

First off, one of the main plot lines was actually based on a true story. Executive producer, John Wells, 17 year old niece died from alcohol poisoning in December. This plot line, in which a teenager is brought in after a night of binge drinking, was written to raise awareness about this issue.

Another case involved a gentleman with AIDS brought in for breathing difficulties. After a workup, he is diagnosed with cancer. When the resident brings up chemotherapy to buy him a few more months, the patient refuses saying that for years now he has just been living for all of his friends who have died from AIDS. "I've been trying to live for them, you know, keep their memories alive. But I've had my time. No regrets." He goes on to describe an experience skydiving and hopes that death feels the same.

Resident: Is there anything I can do for you?
Patient: Yeah, there is. I don't want it to hurt.
Resident: We can help with that.

But to me, the most impressive story was that of an elderly MS patient admitted with pulmonary edema and sepsis. (Sorry, I couldn't find a good clip of this. But the full episode can be legally watched on the NBC website here.) The doctor explains to the husband that they can give his wife IV fluids but it will only do more damage to her lungs. When her husband wants more aggressive things done, the doctor explains that even with aggressive treatments her life will only be prolonged by a week or two (He prognosticates while having a goals of care conversation! Is this the first time that has been seen on TV?) and these things will just prolong her pain and suffering. He then says "It's time to talk about how to make her as comfortable as possible." Later in the episode, the husband is upset that his wife has an apneic episode. The nurse explains that irregular breathing is a normal part of the dying process.

That's quite a bit of palliative content for one episode (even a 2 hour episode). Maybe someone who watches regularly could tell me if this has been the norm. I think that death is commonly dealt with on ER but what I find interesting in this episode is how it is dealt with more as a natural part of life, not always a struggle. Comfort is actually brought up in both of the last two story lines I mentioned. So, farewell ER! While I haven't been a devoted follower, I am a fan of this episode.