To a physician, death can some times be very hard to understand. Since my earliest days in medical school I had been programmed to make every effort to prevent it. When death did occur, it some times baffled me as to whether there was anything else that could have possibly been done to prevent it.

Very few medical schools give a course on the handling of death as part of its curriculum. In my 20 years as a physician, I have witnessed some incredible instances of courage and fortitude among my patients who were dying. I will begin with the two phases of dying and subsequently talk about the five stages of dying. Do Not Resuscitate orders, or DNRs, will be discussed, and, finally, I would like to take the opportunity to tell you about three patients of mine, each with his own unique story who was dying. At the end, I will make a suggestion of when all else fails.

There are two phases of dying, which arise prior to the actual time of death: the pre-active phase and the active phase. On average, the pre-active phase of dying may last approximately two weeks while the active phase may vary and last up to three days. Some patients can actually spend time in the pre-active phase of dying for longer than a month while other patients may exhibit signs of the active phase of dying for up to two weeks.

This may cause confusion to the hospice staff thinking that death may be imminent. Only God for sure knows when death will occur. The signs of the pre-active phase can include restlessness and confusion, withdrawal from participation in social activities, lethargy, and decreased intake of food and liquids. The patient may report that he or she has already died. The inability to recover from wounds and infections along with increased edema of any of the extremities or the entire body may also be noted.

During the active phase of dying the patient may show severe agitation or hallucinations. What is frequently seen are abnormal breathing patterns, as well as urinary and bowel incontinence. The blood pressure may drop dramatically. The extremities get very cold; generally the hands and feet are affected first. This is a normal response that the body is diverting blood to critical organs. The extremities can even appear cyanotic.

There are generally five stages of dying. Not every person goes through all five stages. The first stage is denial. The person generally feels that he is too young to die and has a negative reaction when a physician confirms that death is probably near. The patient may ask for a second opinion or have the results reviewed by another physician.

Stage 2 is anger. You feel helpless. You may be angry with yourself, the system, or possibly the medical staff trying to help you. It may be hard to talk to you at all during this time and your reasoning may be affected.

During stage 3 called the compromise or bargaining stage, the person tries to make deals generally with God. You do certain things to try to buy more time. You may say if I take this medication, lose weight, start eating healthy, and quit smoking my illness may go away. If I do good deeds, God will reward me and cure my illness.

Stage 4 is probably the toughest stage, depression. You are not capable of dealing with everyday problems. You mourn for yourself, as well as the loved ones that you are going to be leaving behind. This is a reactive depression. During this period, you may question the meaning of life. You may actually inventory your life. You may look back at the past and think whether you made the right or wrong decisions. Most people close to the end will be searching for the meaning of life whether in the past, present or future.

The final stage is acceptance. You come to terms with reality that you are going to die. This is, however, the most helpful stage for the individual. You cannot begin living until you accept the fact that you are dying. It is during this stage that you may actually begin to participate in your medical care.

The library, of course, is a good source of information. Organizations such as the National Cancer Foundation or the American Heart Association generally offer assistance. Your doctor, whether it is your primary care physician, cardiologist or oncologist may be the one you seek out for help or it can possibly be a family member or a clergy member.

It is also during this stage when you begin to say goodbye. You start making plans and arrangements for your funeral. You may ask someone to give your eulogy. Mitch Albom's, "Have A Little Faith" is a good book that you may want to read. You may seek out directives for health care and legal matters and setting a guardian in charge of these matters. It is also at this time that you may consider a DNR.

DNRs are generally considered for people who are terminally ill and have no or little quality of life. It may be placed by the patient or by close family members. It can be withdrawn at any time. I have seen one major problem with DNRs. Most people get this order mixed up with "not wanting anything aggressively to be done if things go bad."

They are generally perfectly healthy, but state they do not want to be on a ventilator if things go wrong. This is not a DNR. This is just directives that you should discuss with your physician. I also recommend that generally DNRs be discussed with the entire family. I had one instance where one family member was not in agreement with the rest of the family and at every holiday made the other family members feel bad about the decision.

Act I: It was during my earliest years as a fellow in cardiology that I was taught that people know their bodies better than any physician or any test. My patient, Bill, had been admitted the night before with chest pain. I was the senior fellow on the cardiology service for the coronary care unit. I was making rounds that morning and came in to talk to Bill. I remember walking into his room and introducing myself. After obtaining a history and physical exam, I had informed him he had experienced a small heart attack, but that everything looked stable and most likely we would proceed to perform additional tests.

He told me that he just did not feel right. I examined him for a second time and conferred to him that all the data and numbers showed that he was perfectly stable. He was having no further chest pains. It was then that I never forgot what he told me. He looked at me straight in the eye and with no fear or anger told me that this would be his last day. I explained to him that many patients when told they are sick can become fearful and feel that they may die, but this did not appear to be his case. What was interesting about Bill was that he had no anger or apprehension about what he had told me. He was very calm and again reaffirmed to me that this would be his last day.

We subsequently performed the additional tests and went about our business that day doing further rounds. At approximately 4 p.m. that afternoon the nursing staff in the coronary care unit informed me that Bill had died. The autopsy gave no additional information. We had followed every standard and protocol, but to this day it still amazes me how this one patient knew that it was his last day.

Act II: John was a patient I had been seeing for a long time. He had suffered many heart attacks in the past and suffered from end-stage ischemic cardiomyopathy. His heart was extremely weak and despite maximum medical therapy, he still presented to the hospital on multiple occasions with congestive heart failure. It was obvious that the medications were no longer holding him as they had in the past.

One afternoon after examining him, I explained to him that his chance of long-term survival was slim and he would most likely die within about one year. With calmness, he looked at me and agreed.

He knew he was dying nor had the desire to live or spend more time in the hospitals. He informed me that as part of his last wish he wanted his entire family to be with him. His wife had arranged for his brothers, sisters, and children to be with him. Each spent time individually with him. Then one afternoon while his entire family was in the room, he summoned me to the room. In front of his entire family, he thanked me for the care that I had provided him over the years and wanted to make sure that his final wish would be followed. He asked for a DNR.

I told him that I would respect his wish and such an order was immediately placed. His family had stayed with him for an additional two to three hours again praying over him and telling stories of things they had most remembered about him. As soon as they all had left, he died within one hour.

Act III: James was a middle-aged male that I had never seen before. He presented to the emergency room with chest discomfort. He was having a large myocardial infarction. The cath lab team was called and we were getting ready to take him to the cath lab from the emergency room. He went into a full arrest. We performed the usual chest compressions and must have shocked him 10-12 times.

I remember the ER doctor looking at me stating that we should probably stop the code. I had felt he was still with us. I had asked God to give me an additional three to five minutes in order to place some additional lines. I remember at that point his heart had stopped fibrillating and he went back into normal rhythm, buying me the time that I needed. We were able to transfer him to the heart lab and open up his artery. He went home a week later.

During his follow-up in my office, I explained to him how close he was to dying that afternoon. He then told me the incredible story how he was there the entire time. He could see us working on him. He was able to fully describe who had shocked him, who was placing the IVs, and where every individual was in the room and what they were wearing. He simply stated that he knew it was not his time to go.

The above stories have made me humble when it concerns people who are dying. I always tell people to live as if it were their last day. I have been asked on many occasions when all appears hopeless what else can be done. The answer is always the same. Keep the faith and pray.