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My Woo: A Confession

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?

Of course.

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?

Maybe.

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.

References

  1. What Is Complementary and Alternative Medicine?, http://nccam.nih.gov/health/backgrounds/mindbody.htm
  2. Holidays, Birthdays, and Postponement of Cancer Death. JAMA. 2004;292:3012-3016. PMID 15613670
  3. Neurohumoral Features of Myocardial Stunning Due to Sudden Emotional Stress. N Engl J Med 2005;352:539-48.

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20 thoughts on “My Woo: A Confession

  1. overshoot says:

    Mortality and the calendar

    Your cited study wasn’t the only one. Several have found the so-called “Passover Effect” where death rates in Jewish communities drop by 4-11% in the week before Passover, only to rise a similar amount afterward.

    Mechanism

    I guess I have less of a problem with mechanism when I consider psychogenic shock or documented cases of people (Marc Dawson, recently) who have managed to hold their breaths long enough to die. I’ve certainly worked with spinal-injury victims who were only breathing due to great effort using auxiliary mechanisms, so a reduction of conscious effort on their part would have been fatal.

    We can wooify it with phrases like “mind-body interaction” or we can bury it in enough detail to lose sight of the big picture, but in the end mental state obviously does affect the body or else I can’t explain what my fingers are doing right now to put these words on the screen.

  2. Michelle B says:

    Physician, heal thy woo.

    Interesting article about the mind/body connection (hat tip to Sharp Brains): http://www.blog.newsweek.com/blogs/labnotes/archive/2008/03/25/the-lotus-and-the-synapse.aspx

  3. daedalus2u says:

    There are reasonably well documented cases of death caused by what appear to be only the belief that one is about to die.

    http://www.psychosomaticmedicine.org/cgi/reprint/19/3/182

    Not “proof”, but enough evidence that the default hypothesis that such things cannot ever happen is not likely. People can run themselves to death, that the ANS can be put in a state where death happens does not seem unreasonable to me.

  4. pec says:

    “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. … That intense realization leads to a catecholamine surge and it kills them.”

    That doesn’t make sense. Losing the will to live does not feel like a surge of stress. A man who dies of a “broken heart” shortly after his wife dies, does not seem to be experiencing intense anxiety or fear of death.

  5. weing says:

    I heard about this yogi that told his students about a great yogi that chose the time of his death and willed himself dead. His students then asked him “Can you do that?”.

  6. wertys says:

    If you accept that the brain causes the mind, the whole concept of ‘mind-body’ interaction becomes meaningless. I don’t think it’s woo to observe that the emotional stress brought about by sentinel events in people’s lives such as the death of a life partner or the brutal termination of a lifelong dream can profoundly affect that person’s physiology. It’s what you would predict in fact.

    I do however think that Dr Crislip has shown nicely how you can be a skeptic and acknowledge that this stuff is almost enitrely confirmaiton bias and the law of large numbers at work, yet still acknowledge that as a functioning human with a fallible brain it is possibel to profess an unshakeable conviction about something you know is probably wrong. At least he is not trying to make any money from people by this means !

  7. Valiant Orange says:

    “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.”

    Believe it or not, someone actually does:

    “As I point out above and in my heart chapter in the Fourfold Path to Healing, it is clear that the walls of the heart do not propel the blood. In fact, a more accurate way to phrase the relationship between the heart and the movement of the blood is that the blood pumps the heart.”

  8. Mark Crislip says:

    “That doesn’t make sense. Losing the will to live does not feel like a surge of stress. A man who dies of a “broken heart” shortly after his wife dies, does not seem to be experiencing intense anxiety or fear of death.”

    You must deal with a differen population than I. All the people I have seen lose a spouse or be told they are going to die seem a wee bit stressed to me.

  9. mckenzievmd says:

    “You must deal with a differen population than I. All the people I have seen lose a spouse or be told they are going to die seem a wee bit stressed to me.”

    This seems disingenuous. “A wee bit stressed” and an acute, fatal catecholamine surge are two different things. I don’t have your personal experience, so I can’t coment on the plausibility of the general idea that peopel can “will” themselves to die at a certain time, but on general priunciples this suggested mechanism is pretty shaky. Most surviving spouses don’t die acutely of the shock of learning a spouse is gone, which might be more consistent with this theory.

    In the absence of real hard data, a provisional belief in something based on personal experiences isn’t totally unreasonable. Now if the data ever becomes available and you refuse to give up the idea anyway, then you’ll have something to confess. ;-)

  10. Joe says:

    pec wrote “That doesn’t make sense. Losing the will to live does not feel like a surge of stress. A man who dies of a “broken heart” shortly after his wife dies, does not seem to be experiencing intense anxiety or fear of death.”

    pec, you continue to dazzle us with your …

    Pray tell, whence is this “insight” derived. Is it the same place that told you preventive medicine was developed by chiropractors? You know- the cult that preaches against vaccination.

    If “Losing the will to live does not feel like a surge of stress.” What does it feel like?

    If “A man who dies of a “broken heart” shortly after his wife dies, does not seem to be experiencing intense anxiety or fear of death.” What does he seem to be experiencing?

    Since you commented, you must know these things.

    Does anything embarrass you?

  11. kathleen says:

    “There are reasonably well documented cases of death caused by what appear to be only the belief that one is about to die.

    http://www.psychosomaticmedicine.org/cgi/reprint/19/3/182

    That was really interesting …..but are there any well documented cases more recently than 1942?

  12. kathleen says:

    “Most surviving spouses don’t die acutely of the shock of learning a spouse is gone, which might be more consistent with this theory.”

    The death of a surviving spouse seems to be reported fairly frequently and put down to the fact that ‘she/he couldn’t live without him/her’. But the period before the spouse dies can be anything from a few days to a year or so. Given that we are probably talking about an elderly population (does it ever happen to younger people?) I would have thought that this could be put down to coincidence, to the surviving spouse not taking sufficient care of him/herself, or even to a suicide that is not reported as such.
    This seems to be a slightly different phenomenon to that of someone (either previously healthy or extremely ill) who can will themselves to die.

  13. DBonez says:

    An anecdotal account of death.

    Nine months ago, my wife of 16 years died of metastatic angiosarcoma. She went from a wonderful, vibrant, healthy, athletic woman to dead in just a few weeks. She was 35.

    Shortly after, I experienced extreme depression and grief. I withdrew from much of life and wallowed for a time coming to grips with what had happened, why it happened, and what things were going to be like.

    During that time, there were periods that lasted for several days each, where I was extremely sedentary and ate nothing. All of my natural rhythms and normal drives to eat, sleep, and move were completely removed. I never felt fear or anxiety. I also felt no pain and little ill-effects from the lack of nutrition and water. Fortunately, I stepped back up to life and returned to living being proactive about recovering from the tragedy I had just experienced. I have been fully engaged with life for quite a while now and am again happy, healthy, and positive.

    However, I can absolutely see where someone lacking the drive to recover, as I did, or an elderly person who spent a majority of their life in a relationship, could remain withdrawn for months, years, or for the rest of their life. I can also see where someone in those extreme situations could simply remain in a chronic depressive state and waste away to the point of death. Their death would likely come from (forgive the layman’s analysis) malnutrition, dehydration, the forgoing of medications, lack of activity, or whatever form of organ failure that would result from some or all of those factors.

    I don’t know if I would use the term “will yourself to death,” but I think you could “will yourself not to survive” ignoring/repressing all normal survival instincts. And, without some external intervention, or some conscious desire to survive, one could die.

    One could argue that there is some woo-factor in this, after all, it would be the mind and mental state ignoring all the powerful innate drives to live, but death would still be a physiological event. I’m not sure how I feel about applying woo here considering one could, if properly motivated, run themselves to death or commit suicide, so clearly the mind can force the body into some horribly unnatural situations. I think woo would imply anybody at any given moment sitting down and killing themselves quickly with just thoughts. What I’m describing would be a slow, purposeful, though not intentional, slip into death much the same way a person with brain damage might die within days or weeks without external support.

    Great post . . . as always.

  14. Mark Crislip says:

    to DBonez: whoa. my sympathies.

    to mckenzievmd: while I have been on line since my 300 baud modem and my 128K mac, I am new to communicating with blogs.
    The lack of tone and facial expression makes translation of my thoughts to words incomplete, I am going to have to work on my style. I realize a little late that sarcastic understatement doesnt work in print. Is there an emoticon for that ?

  15. Michelle B says:

    How about willing yourself to live?

    Decades ago, a few months before my 18th birthday, my Mom endured her 3rd heart attack. She promised me not to die until after my 18th birthday because before that date I would still be a minor and subject to living with rather undesirable relatives. She died about a week after my birthday. I felt at the time and still do, that it was just a coincidence.

  16. badger3k says:

    I’m trying to remember where I read that this idea that people can hold out and die after a certain event (this only applies to those who are dying) is just a myth. There were some studies (of some kind) that showed that this idea was basically confirmation bias and remembering the hits – people were more often to relate stories of people who died after such events, and not relate those that didn’t. My mother had cancer, and she was dying. She took a turn for the worse after seeing all of her kids and grandkids. Do I believe that she held on, then died after she had achieved her goal? No – you could tell the progress of the cancer and see no relation to her desires. Most of the idea is coincidence and bias.

    That said, I do believe that our mental state has an affect on our health, just not to the extent that we can fight off death if our body is too far gone.

    As for people dying after events, or the rest in the post, I don’t know enough to really have an opinion other than “I don’t know”.

  17. BlazingDragon says:

    My grandfather was an example of living far past when he should have been dead (metastatic cancer all over his body). Given the sheer stubbornness in both sides of my family, it’s hard not to attribute his living for almost a year after being told he had 3-6 months to live to “willpower.” He was bedridden and had to be taken care of 24/7 for 9 of the 12 months after he was diagnosed, but somehow continued to live. After this agonizing period (my mom, her sister, and my grandmother were the most badly impacted because they did a lot of the care for him), my grandfather appeared to give up the fight and was dead in a few days.

    It’s only an anecdote and an n of 1, but given how stubborn my grandfather was, I think he was able to extend his life by “not giving up.” I don’t think there is any woo involved, however :)

    It seems perfectly plausible that, given a condition which is borderline for dying, a strong “will” could keep one on the “correct” side of the ragged edge (fighting harder to keep breathing, remembering to take pills, keeping well-hydrated, taking in adequate nutrition despite nausea, etc). Of course, this will only work until the body’s systems are totally exhausted, but it might, in rare cases, give a few people a few extra days to a few extra weeks. I don’t think woo has to be involved at all.

    The family stubbornness didn’t help my aunt (an RN who knew how to take care of herself) from the ravages of MRSA … she was gone in about a week (3 days after being hospitalized), so the ability to “hold back death” doesn’t apply to every terminal condition.

  18. Calli Arcale says:

    I know of one case. Happened before I was born, but it’s popular lore in my family. My great-grandfather really wanted to see his eldest granddaughter get married. Sure, he was hospitalized and a little dotty by that point, but he was adamant and evidently at least somewhat clear-headed. One day, the hospital noticed he was gone. He’d walked home. It was the day of my mother’s wedding. He was dressed only in a hospital gown, and it was December in Minnesota. The family found him and contacted the hospital; it was decided all around that he might as well attend the wedding, so they got him cleaned up and dressed nicely. The next day, they took him back to the hospital, where he died shortly thereafter. Mind you, the walk home in the cold may have contributed, even though it was unseasonably warm (somewhat above freezing).

    Last November, I saw someone choose her time to die. But it wasn’t the same at all. Unable to wean off of the ventilator, and having lost her vision, she decided to have the ventilator turned off; she wanted to go. Despite wanting to die that day (actually, she wanted to go the day before, but delayed one day so that a relative could arrive to see her one last time), it didn’t happen quickly. Doctors had predicted she’d only last an hour, and she lasted six.

    And the previous September, I saw another person choose to die. Only he was not successful. He was certain that he was terminally ill, arranged for hospice care to control his pain, and stopped eating. After about a week and a half, he decided that he’d had enough of that and started eating again. He’s still around now, and is doing much better. He told me he was actually praying, asking God why He wouldn’t take him yet. So he’s an example of someone *unsuccessfully* choosing to die. I wonder how numerous those people are? How many people are trapped in their bodies, hoping for death, desperate for it, and yet unable to will themselves to die?

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