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Doctor’s Diary: Till Death Do Us Part

Geoffrey Simmons
Photo credit: Aron Visuals via Unsplash.

According to Gautama Buddha, “We begin to die from the moment we are born, for birth is the cause of death. The nature of decay is inherent in youth, the nature of sickness is inherent in health, in the midst of life we are verily in death.” The Japanese writer Huraki Murakami once wrote, “Death is not the opposite of life. It is part of it.”

Why any one person’s life ends is very hard to explain. But, not how. 

On a recent ID the Future podcast, Stephen Meyer commented that there is something about life that is greater than the sum of the parts. On the same podcast, James Tour asked about cell death. Nothing appears to change the moment a cell dies. All the parts are present, but signs of life under the microscope are missing.

Race to the Finish

Each person’s race to the finish begins at conception. The passage of time is marked by dwindling telomeres. Even though we humans pride ourselves on having different roadmaps, we are all pretty much the same. We begin to walk and talk at roughly the same time. In later life, most of us turn gray and/or lose our hair; and, after 40 we slow down at similar rates and in nearly identical ways. (See my article for Evolution News, “Doctor’s Diary: On Designed Obsolescence.”) We typically die between ages 65 and 85. With very rare exceptions, few of us live beyond 126 years. 

As an attending physician, I have witnessed death many times. The end of life often follows a clearcut blueprint; this is particularly evident when death is imminent and expected. Signs of intelligent design are evident as if following a DIY pamphlet. Like Elisabeth Kübler-Ross’s five steps of grieving — Denial, Anger, Bargaining, Depression and Acceptance — we pass through somewhat similar steps of Realization, Doubt, Sadness, Resolution, and Acceptance. Oftentimes, death is harder on the living than the dying. Acceptance among the dying often precedes acceptance among the survivors.

As the End Approaches

There are successive, overlapping, common, and cumulative physical changes seen as a person approaches the end of life. These include a mental and physical withdrawal from life, decreasing appetite and striking weight loss, less desire for social interactions, increasing somnolence, changing toilet habits, worsening vital signs, especially the dropping of body temperature, weakening muscles, sometimes increasing pain, confusion/hallucinations with possible agitation, some congestion (these people cannot clear their secretions), and lastly, a deepening sleep. At the moment of death, the pulse ceases, breathing stops, muscles become limp, pupils become fixed and dilated, there is pallor, skin is cool to the touch, bowel and bladder release, and arousal from sleep is impossible. We all do this. Not uncommonly there’s a relaxed, almost euphoric grin. Few of us die with a grimace. Life is gone, yet all the parts are still there.

Traumatic and early deaths are a little different, although they also seem to me to show signs of intelligent design. We see this in nature, for example, when a tiger takes down a gazelle. The prey immediately collapses in the jaws of the predator. Granted, this could be due to the sudden crush of the windpipe and low oxygen, but it may also be, in part, due to the sudden rush of endorphins and mental mechanisms to lessen suffering.

We commonly see evidence of amnesia in people who have survived truly life-threatening assaults. I suspect it’s a normal coping or defensive mechanism. Many of these victims will have no recollection of the event for days, sometimes for life; medics often report a minimum of reported pain despite gaping wounds. Again, it might be low blood pressure and/or low oxygen, but oftentimes it seems to be more than that. 

My Experiences as an ER Physician

When I was in charge of the Emergency Room at Los Angeles County Hospital, I saw many instances of near-death trauma, yet there was little complaint about pain during the immediate care period. In practice, pain was related more to lesser injuries and chronic problems — a different phenomenon. I once took care of a Russian fisherman who was severely injured after being trapped in his trawling equipment. His memory of that day stopped with the preceding meal; he never recalled the two hours before the accident or days in the hospital even though he was very conversant throughout. He could not recollect any pain yet the injuries were deep and numerous. 

Another patient was severely injured when a speeding car struck his bicycle. He was on his way to work and fortunately was wearing a helmet, which was smashed.  Later, he recalled leaving his home and saying goodbye to his wife. But, that’s it. His next recollection was weeks afterward, yet he was conversant in the ambulance.

One might say my stories are anecdotal, but there is substantial evidence to the contrary.

It’s widely known that severely wounded soldiers during wartime may not feel pain, when excruciating pain is what you might expect. During 1943 and 1944, an American physician, Henry K. Beecher, traveled to the Italian fronts and interviewed 215 seriously injured servicemen who were waiting to be evacuated to a hospital. He found that there was no correlation between the seriousness of a wound and the men’s degree of suffering. Three-quarters of the men said they weren’t experiencing significant pain and didn’t need pain relief, even when it was offered. One-third said they weren’t experiencing any pain. In fact, there’s a joke, of sorts, among paramedics about dying soldiers who complain more about the pain from an injection or IV than from their wounds. Perhaps. The mechanism blocking the feeling of pain is emotional and/or endorphins. Or, both. Either way, it must be there by design.

A Body-Wide Standstill

The standstill from death happens throughout the body. It affects trillions of chemical reactions, every cell’s routine activity, everything flowing through the bloodstreams, every tissue function, every bone, every joint, and every organ. It seems to be more than just the halting of electrical pulses. The change is not as simple as turning a light switch off. Although the heart’s electrical system has a back-up pacemaker, actually two, neither is recruited into action. Lungs do not have a back-up system. Why not? The brain waves cease; there is no generator for power outages. There must be a reason. The “Frankenstein” shock giving life to that monster will not, with very rare exceptions, bring about life.

After death, everything that is considered to be soft tissue slowly reverts to whence it came. It dissolves and disintegrates. Nature has its clean-up crews already in place, within and without, as it does across Nature. Forensic pathologists make use of a standard timetable to determine the moment and sometimes the mechanism of death.  

Is there a spirit or soul that comes in the beginning and leaves at the end? What makes all these systems work so well together from the first day to the last day? What is it in that half-baton of life passed from mom and dad to the child that starts this biological engine? These are among the many fascinating questions with which we are left.