Mar 27 2008
It’s a case of mind over matter. I have no mind but it doesn’t seem to matter.
— George Burns
I should be working on my taxes. Instead, I’ll dwell on the other, more pleasant, inevitability.
Its been a bad couple of months for death. Everyone dies, and people often die of infection, but the flu season has been busy and with the MRSA lurking in the community, I have seen too many young die who should have otherwise survived their influenza.
I spend most of my professional day working in an acute care hospital, and most people in the hospital die of something. They die when their heart or lungs or liver or brain or some combination sustain more damage than can be compensated for. People live within fairly narrow operational parameters and when those parameters are exceeded for any length of time, they die. It is never a surprise when people die due to organ failure past the point of return or support. That is the cause of death in most of the patients I see.
Sometimes, and not very often, people die of nothing in particular. They just die. You get an autopsy, and there does not appear to be any single event that caused the death, nor does the sum of the underlying diseases seem to have lead to death. Usually it is the advanced elderly who just die. There reaches a point where the organism shuts down. I once had a patient die as I walked into the room on rounds. He looked at me and then died. He had many medical problems, but none that should have killed him, and his blood work on the day of death was normal and his autopsy had no clue as to why he died. Creepy. I like to have a definitive cause of death, but I do not always get one.
Then there are the people who appear to choose when they die. Not active suicide. There appears to be a small number of people who make a conscious decision that their time is up and then they die. It is apparently a rare phenomena. Phenomenon. One of the two. When it does happen, though, it makes quite an impression. Death is always an impressive event, when the patient seems to consciously choose the time they die, it is all the more impressive.
Those who choose to die come in two types. There is the old person, usually the male, who has been married for 60 years who loses their spouse. Shortly after the spouse dies, they die. As best as can be determined, they give up and die of nothing. Or perhaps a broken heart. Or, depending on the marriage, an excess of joy.
The other is the cancer patient or other terminal disease who has a personal goal: a wedding or a birth or a reconciliation or some other idiosyncratic reason to postpone death. These patients are few, but do seem to hang on until they reach a goal, then they die.
If you ask doctors who deal with terminal patients, they uniformly agree that this phenomena exists (personal communication). I certainly have had enough of these type of experiences that I have always considered it a fact, based entirely on personal experience, that occasionally people choose when they die. They were rare events, as most people who die do so under circumstances totally beyond their control.
I never saw the point in ‘mind-body’ medicine and the power of mind over matter. Such practices always seemed to put Descartes before the horse. The mind is the result of the function of the brain, just like the blood pressure is the result of the pumping of the heart. No one ever talks about some mystical heart-blood pressure relationship. The components of ‘mind-body’ medicine, such as “relaxation, hypnosis, visual imagery, meditation, biofeedback, cognitive-behavioral therapies, group support, autogenic training, and spirituality (1) “ do not alter disease course in an objective way.
Clinically I never saw any benefit in thinking good thoughts and having a good attitude when it came to disease progression. Happy or sad, upbeat or a downer, disease marched along to its own drummer. A good attitude may help a patient tolerate their illness, but alter disease course? Never. I read Norman Cousins and was unimpressed, as much as I love the Marx brothers. While I expect disagreements from this post, Duck Soup is the funniest movie ever made. End of story.
I never really thought about the apparent conflict that choosing ones time of death was an apparent example of of ‘mind-body’ interaction and my dismissal of the whole concept. They existed in different sections of my mind and I never thought about the contradiction. After all, the hallmark of an educated mind is the ability to hold two diametrically opposing and conflicting ideas simultaneously. By this definition, I know quite a few highly educated people.
Usually when I read the skeptic literature there is a lot of agreeing with what I read. If there was ever a member of the choir, it is me. I’m the one in the castrati section. “Yeah, I know that. Yeah. I agree. Interesting. Makes sense with my world view.” Lots of nodding ‘yes’ as I read.
Then I saw a reference to a paper that suggested that patients could not delay death. For the first time ever when reading a skeptical article I thought, wait. That’s not true. That completely goes against all my experience. No way. It is jarring to read information that goes completely against your deeply held beliefs, especially when it occurs in a source that is trusted. It’s kind of like finding a support for homeopathy in Nature. Such things cannot be. It violates the perceived natural order of the universe. When presented with information that violates your world view, you can a) ignore it, or b) read the original source. One thing you learn in medicine is what people say an article says and what it really says are often two different things.
So I found the original reference (2).
What they did in this study was look at birth certificates of 309,221 persons dying with cancer and to see if their deaths occurred near Thanksgiving, Christmas or their birthdays. There was no correlation with dying and those dates. If there had been, there would have been a spike in deaths after those days. The presumption is that Thanksgiving, Christmas and birthdays are worth living a little longer for, and if you are dying of cancer, you would put off your death to reach those special days.
I have terminal cancer, but let me live just long enough to experience one last drunken, dysfunctional family get together. Seems reasonable to me.
They did find that for “black individuals there was an increase in cancer deaths in the week before Thanksgiving (P = .01), whereas women showed an increase in cancer deaths in the week before their birthday (P = .05).”
Yawn. This is the “Mars Effect” for deaths. An unimportant data spike.
Large epidemiologic studies are not going to answer the question: can people choose when they die. Partly because the event is rare, but more importantly because what causes people to put off death is more personal and idiosyncratic than Christmas or a birthday.
The authors realized this:
personally salient events such as weddings, anniversaries, and graduations could present greater emotional impact for the individual with cancer and thus have a greater effect on the timing of death. Unfortunately, no practical means exist to ascertain the impact of these events in large population-based registries for the hundreds of thousands of persons dying of cancer. We are additionally unable to determine from our database the proportion of individuals who were comatose before death and therefore were incapable of knowing the approach of a holiday.
It is a small point, but are people postponing their death or are they waiting for an event and deciding to die? The first suggests they are overcoming, by will power, a physiology that should have killed them. The latter suggests that there may a process whereby patients choose when they die. These are not the same thing.
So is there any biologic plausibility that has me hanging on to this little bit of woo?
It is a frequent question from patients: the role of stress in their illness. I usually give some answer to the effect that stress is bad, but it is hard to quantify the effects on an individual: stress can increase disease risk, but I can’t really say that it is a specific stress that causes a specific illness. Unless, of course, the stress kills you.
Can you die of a broken heart? Or be scared to death?
In the NEJM from 2005 (3), they looked at
19 patients with “stress cardiomyopathy,” a syndrome of profound myocardial stunning precipitated by acute emotional stress, in an effort to identify the clinical features that distinguish this syndrome from acute myocardial infarction and the cause of transient stress induced myocardial dysfunction.
These patients had heart failure, often severe, from stress. What was the stress? Family deaths, bad news, arguments, even a surprise party or two.
The cardiac effects? arrhythmias, heart failure, a small bump in their cardiac enzymes (which occurs in a heart attack).
The cardiac evaluation? a markedly decreased cardiac pump function and normal coronary arteries. No anatomical reason found for the heart failure.
The putative reason for the cardiac dysfunction? markedly elevated catecholamines (epinephrine, norepinephrine, dopamine, metanephrine and normetanephrine) as well as other vasoactive substances: 2 to 3 times the level of heart attack patients and 7 to 34 times the levels in normal people.
What does that mean?
It means that stress can cause a massive bolus of a potentially fatal vasoactive chemicals; what is popularly called an adrenalin rush. These high levels of chemicals are potentially directly toxic to the heart, although the exact mechanism of the damage is speculative. I would venture to guess that an older heart would be more susceptible to the ill effects of such a surge.
There is biologic plausibility to suspect that people can die from the stress of a broken heart or be scared to death.
How is this related to choosing when to die?
Imagine you have a terminal disease. Many people intellectually know they are going to die, but perhaps they haven’t had that emotional understanding of their mortality yet.
They decide they want to wait for a wedding, a birth, or a reconciliation. The event occurs. They realize that they have nothing to live for and have that “holy moly, I am really going to die” moment. It hits home that, to quote P. Pig, “that’s all folks.” That intense realization leads to a catecholamine surge and it kills them.
They ‘chose’ the time of their death.
If that is the mechanism of choosing the time of death, then it would be be testable in that one could measure catecholamine levels at the time of death in these patients, although it would be a logistically awkward study to perform.
Intellectually, I know that I am suffering from an enormous confirmation bias from witnessing extremely emotional events. I am remembering hits and have no way of knowing how many misses there were. I know there is no good data to support the contention that people can occasionally chose their time of death. I have too many personal experiences, as do my colleagues, to disbelieve. I am, heaven forbid, choosing an irrational belief based on anecdotes over science, although in my defense I do not find the studies compelling that suggest that people cannot choose their time of death are flawed. I have biologic plausibility on my side.
I am not yet dissuaded of my underlying belief, or to elevate it, I’ll call it my clinical observation, that rarely people can decide when to die.
That’s my woo and I am sticking to it.
- What Is Complementary and Alternative Medicine?, http://nccam.nih.gov/health/backgrounds/mindbody.htm
- Holidays, Birthdays, and Postponement of Cancer Death. JAMA. 2004;292:3012-3016. PMID 15613670
- Neurohumoral Features of Myocardial Stunning Due to Sudden Emotional Stress. N Engl J Med 2005;352:539-48.
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