IF SYMPTOMS PERSIST By DR. JOSE PUJALTE, JR.

“He was my North, my South, my East and West

 My working week and my Sunday rest,

 My noon, my midnight, my talk my song;

 I thought that love would last forever, I was wrong.”

--   W.H. Auden (1907-1973) Anglo-American poet,  “Funeral Blues” (1936)

Dr. Jose Pujalte Jr. My mother lies comatose in the ICU as I review this article. She lies still with nasty tubes violating her beautiful face. She is comatose, we are catatonic. Caregiving to the gravely ill or even the moribund is physically and emotionally draining. While it demands steady compassion, some form of “clinical distance” is necessary to carry out duties efficiently. A dedicated caregiver – usually a loving relative – should be able to know when death is near. He or she is then in a position to inform other loved ones of the inevitability.  A dying person may have final requests that he wishes done. Sometimes there are explicit instructions for funerals, finances, and so on. Pre-Active Phase. The terminally ill are sometimes not told by well-meaning (but misguided)  relatives that they have a few months to live. Yet the dying knows that he or she is and behavior becomes uncannily universal. The pre-active phase of dying can last from weeks to months. These are observed:

• Withdraws from social activities to spend more time alone or at home.
• Becomes concerned with finances, insurance, or wills.
• Seeks out estranged relatives and friends.
• Begins to talk about dying.
• Loss of interest in eating and drinking.
• Increased anxiety.
• Increased periods of lethargy or sleep.
• Recovery from infections slow down or wounds if any no longer heal.
• Increased edema (usually swelling in the extremities).
• Apnea or temporary periods when breathing stops either when awake or asleep.
• Shows interest in speaking with a priest or pastor or
• May remark that he/she is beginning to see dead friends and relatives.

            Active Phase. The active phase of dying is of course much shorter and may take days to a few weeks. These are common observations:

• Breathing is labored and irregular – sometimes slow then fast and shallow – the respiratory system is clogged with secretions and fluid builds up in the lungs (congestion).
• person may state that is he/she is dying soon.
• difficulty swallowing food and drink.
• movement is slow and person prefers not to move.
• hands, feet, arms, and legs are cold to touch.
• skin becomes mottled purple or blue.
• urine becomes dark.
• incontinence, both urinary and bowel.
• dropping blood pressure.
• marked fluctuations in behavior from agitation to hallucination to serenity.
• eventually, in the final stage, loss of sight, taste, smell, feeling, and hearing.

Can’t Live Forever. We cannot really choose how we ought to die but it seems that the ideal way is to be in the presence of loving relatives and friends. Some die suddenly and violently (car crashes, drowning, explosions, bombings, falls, strangling, shootings, and stabbings, etc.). Then there is disease. Still, others live full robust lives all the way, sleep one night and never wake up. To pop aging guru Raymond Weil, MD, this is the way to go. That is, being healthy until the very end and simply slip one day into eternal sleep. But the fact remains that many may die, and have been dying, painfully. That is why responsible caregivers should make a dying person’s remaining weeks and days as comfortable as possible. That starts from an understanding of physical death. As for Mama, I am her son but I am also a doctor. To talk of “clinical distance” is at once subversive and odd as though I wasn’t raised right. How can one talk of Glasgow scores (she’s a 5 = severe brain injury) and at the next breath whisper to her “Ma, gising na!” (wake up!)? The doctor and the son are in direct contradiction. But both love her no less, as everyone does in our family. And she is, as much near death as she is with great hope, near life. Dr. Pujalte is an orthopedic surgeon. email [email protected]