In Your Words  |   September 2012
Just Throw Me to the Lions
Author Notes
  • Address correspondence to Solomon M. Pearce, DO, Department of Physical Medicine and Rehabilitation, Baylor University Medical Center, 4808 Berridge Ln, Dallas, TX 75227-2703. E-mail:  
Article Information
Emergency Medicine / Physical Medicine and Rehabilitation / Being a DO / In Your Words
In Your Words   |   September 2012
Just Throw Me to the Lions
The Journal of the American Osteopathic Association, September 2012, Vol. 112, 632-633. doi:10.7556/jaoa.2012.112.9.632
The Journal of the American Osteopathic Association, September 2012, Vol. 112, 632-633. doi:10.7556/jaoa.2012.112.9.632
“For the last time, I will not throw you to the lions!” My wife's frustrated declaration reverberates through the kitchen, ending our living will discussion emphatically. From my perspective, it makes perfect sense. I was a biology major in college, so I view being thrown to the lions as just a logical way to speed my contribution to the carbon cycle. I get to feed both my love of epic last stands and the lions' hunger. The lions, in turn, are nourished by my energy, and what they can't use, they can leave to the insects and the plants. Simple. No fuss, no bills, no time that my family will ever have to spend praying for my death to end the suffering of some long, drawn-out illness. I think my plan is brilliant, but my experiences as a physical medicine and rehabilitation resident have shown me the absolute importance of both having a living will and making sure your family agrees to your wishes. 
No patient illustrates this point better than Robert. If ever there was a prototype on whom Dos Equis beer based their “The Most Interesting Man in the World” campaign, it was Robert. Robert led a fascinating life. In short, after his family fled their homeland during World War I, his parents were tragically killed and he was left to raise himself on the streets. He had incredible adventures growing up, lied about his age to enlist in the military, and became an honored veteran. After the war, he became a competitive athlete, married, and moved to the United States. Here, he embodied the American Dream: he started out as a laborer, advanced through management, and eventually owned his own company. He had numerous hobbies and countless friends. He had lived life, not just stood by passively procrastinating away the years until the inevitable, like David. 
David lived in the same medium-sized town in which he was born. He finished high school and went to work in the same blue-collar job as his father. He married his first girlfriend but had no children. He had never traveled outside of his home state or had even been to “the big city,” which was only 45 minutes away. Six days a week, David went to work, came home, and spent the rest of the night in front of the television, just as he had during the past 30 years. The only deviation to his routine was on Sunday, when his wife made him go to church with her. 
What amazed me was that, despite their array of differences, Robert and David had 2 things in common: First, they both had found their way to the same hospital room, and second, they both had taken the time to create living wills. 
Robert's will was meticulously detailed and specific to every situation. It had been drafted by an upscale lawyer and was kept neatly organized with other important papers in a safety deposit box at his bank. David's will was simple—“try everything”—and was scribbled hastily on a piece of paper as one of the fringe benefits of signing on to work for his company. He had mentioned the will to his wife years ago in passing as he threw it in an old shoe box kept on the top shelf at the back of their closet. 
I knew nothing of Robert's and David's living wills when they were admitted to the hospital. Robert, still fit and working out daily, was in his eighties and had been struck by a car while he was riding his bicycle. He was brought to the hospital and, despite the fact that his living will said he did not want to be revived, was vigorously resuscitated at his family's request. The trauma team had been able to save him, but he had suffered a burst fracture of the C2 vertebra with retropulsion into the spinal cord, leaving him with tetraplegia from his complete spinal cord injury. He had a tracheostomy and was ventilator dependant. In addition, he had a percutaneous endoscopic gastrostomy tube punching through his stomach to feed him and another tube in his bladder, and he now lived in diapers. His family battled with both grief and guilt for going against his wishes. Eerily, Gary Jules' voice singing
And I find it kind of funny
I find it kind of sad
The dreams in which I'm dying
Are the best I ever had
would not stop playing on the radio in his room. It truly was a “Mad World,” and it was exactly what Robert had in mind when he had filled out his living will to never be resuscitated. 
David's story was different. He had been at work when, suddenly, he lost feeling in his feet. Coworkers ran over and lifted him to the ground, where he fell into a coma (later discovered to be from a massive hemorrhagic stroke). His wife had been by his side nonstop in the hospital, but, after 2 weeks with no sign that he would ever wake up, she agreed to palliative care and to let him die. During the next week, she spent a little more time at home each day, trying to get things in order for his death, when she happened upon that old shoebox with his living will. As she reread his simple request, she remembered one of his doctors talking about neurostimulation and decided to have him transferred to a rehabilitation hospital so she could rest easy knowing that she had tried everything. 
Living wills at their simplest lay out our desires in case we are not able to communicate our own wishes, like Robert and David. They usually consist of a few questions that ask whether or not you would want life-sustaining treatments in certain situations. For instance, if you were in a coma, had severe brain damage, or had injuries that would make you completely dependent on others or machines, or if it was known you would die very soon despite any intervention, would you want life-sustaining treatments? 
Advanced directives are often coupled with living wills and include naming someone to make medical decisions on your behalf and what, if any, form of resuscitation you would like in the event of an accident or illness. They take only a few minutes to fill out and should be something we recommend to all our patients. They are easily accessible from a lawyer or employer or, in this day and age, free on the Internet. For those addicted to their smart phones, yes, there is even an app for that. 
It was because of Robert that my wife's face had that crimson glow, that her eyes glistened from the uncomfortable conversation, and that our children, usually underfoot, had mysteriously disappeared to their rooms on their own. I wanted to be sure that even if it wasn't my first choice with the lions, I had a plan in place that we both understood and would both follow. 
As Robert regained his strength, he would at first mouth the words and later whisper that he wanted to “try it” without the ventilator. He was well aware of what this meant, from multiple discussions with doctors privately, as well as from family conferences. He jokingly referred to it as his last VO2 max (a test often used by endurance athletes to measure their ability to consume oxygen). He was now strong enough to explain his desires to his family, and an incredible sense of peace replaced the weeks of uneasy tension. 
Not long after Robert's decision, David's wife frantically waved me down from across the therapy gym. She had just pushed her husband's wheelchair back inside after enjoying the sunshine on the patio, when I noticed that her face was streaming with tears and her hands were trembling. I quickly asked what was wrong and if there was anything I could do to help. She explained that David had just told her that he loved her. As I looked at this beautifully hopeful soul, she must have read the skepticism flash across my face. After all, this was a man who, during the past 3 ½ weeks, had not responded to any voice or touch—he didn't even give the slightest flinch as needles were inserted in his arms for blood draws, despite an aggressive neurostimulant regimen. He was a few days away from being labeled as being in a persistent vegetative state. She reiterated, “He just told me he loved me! And then he asked to go back inside because it was too hot out.” I called his name and rubbed his shoulder and, to my amazement, David then responded with a gruff “What?” I followed him to his morning therapies and saw one after another seasoned therapist almost soil him- or herself as David engaged in conversation. Both he and his wife would later say that despite any disability, that first “I love you” made it all worth it. 
Regardless if it's Robert's peace or David's love that inspires you to act, take the time today to make sure your wishes will be followed by creating a living will, discussing it with your family (because surprisingly some fail to see the appeal of going down raging against the lions), and encouraging your patients to do the same. It takes only a few minutes, but it is one of the few ways to care for your patients for an eternity. 
I sincerely thank Rita G. Hamilton, DO, for her kindness, devoted advocacy, and tireless support in the preparation of this manuscript. 
   Financial Disclosures: None reported.
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