Deep thoughts about death and heart disease

~ Carolyn Thomas

by Carolyn Thomas  ♥ @HeartSisters

I loved reading the late Yale Medical School professor Dr. Sherwin Nuland’s highly-recommended book How We Die – which is not nearly as grim as it may sound. In fact, it’s an endlessly fascinating read. For heart patients, the concept of death can suddenly become far more personally compelling than most of us ever imagined it to be.

But we live in a death-denying society. People don’t want to think about death, much less talk about it. As Dr. Nuland wrote, death to most of us occurs “in sterile seclusion, cloaked in euphemism and taboo”. We don’t even like using the ‘D’-word. Instead of ‘dying’, some of us prefer to just “pass away” or “go to be with Jesus”.

Sometimes, it seems that we consider death to be a terrible mistake that should never ever happen to anybody, instead of the inevitable end result of being born. But let’s face it, my heart sisters:   none of us is getting out of here alive. . .

My own personal view on the subject of death is just that – my personal opinion that you may or may not share.

Perhaps it was so many years working in end-of-life/palliative care (where our staff tends to chat comfortably about death and our own mortality compared to the average person on the street) that made me so intrigued by life’s final chapter.

I’ve seen really awful ways to die (my own Dad’s, for example – a non-smoker who died of metastatic lung cancer at age 62).  The doctors told my mother they were “reluctant to give him morphine because it’s addictive”.  He died nine hours after that conversation. But at least he didn’t die an addict. . .  

I’ve also been privileged to witness on many occasions what any caring person would consider a good death supported by caring professionals (skilled palliative care physicians, nurses and bereavement counselors).

And I know of anguishing examples of heroic yet futile efforts by some physicians to artificially prolong life, efforts that not only hold absolutely no hope of being successful, but often result in unspeakable suffering for both patients and their families.

Post-heart attack, after being discharged from the CCU (the Intensive Care unit for heart patients), I became suddenly worried that I would die in my sleep, that I might never wake up. I wasn’t so much worried, actually. More like convinced. I didn’t seem to feel upset or afraid. Instead, I just KNEW that tonight was going to be my last on this earth.  So each evening at bedtime,  night after night, I tidied up the apartment, took out the recyling, wiped down the countertops, and scrubbed the bathroom. But after a few weeks of this, I realized how exhausting it is to dread death – especially death that doesn’t come.

I am also relieved and grateful to live in a time and place here in Canada, where Medical Assistance In Dying (MAID) is now legally available upon request for those who qualify under tightly specific guidelines. It is my own personal wish to take advantage of a physician-assisted death one day if I’m ever in that state of intractable physical or mental suffering I can no longer tolerate.

I’ve had a remarkably good life. And more convincingly, I spent 10 years of my life visiting my brilliant, funny, eccentric friend in her 5-bed longterm care ward after a catastrophic stroke that left her incapacitated, strapped into a wheelchair, incontinent, almost blind, nearly deaf, and severely depressed.  After the first four or five years of our regular visits, she started telling me, “I wished they had never saved my life.”

I know that there are far worse things than death.

Unless a catastrophic accident gets me before I qualify for MAID, heart disease or its complications will very likely be implicated in my death. Dr. Nuland’s unique book looks at the medical physiology of how we die if we do die from illness – from cancer to Alzheimer’s and, yes, cardiovascular disease.

It’s still surreal to read Dr. Nuland’s description of our coronary arteries as “friends of the heart” when we are healthy, but “when they are diseased, they betray it at its most needful moments.”  He explained:

“So commonly do coronary arteries betray the heart whose muscle they are meant to sustain, that their treachery is the cause of at least half of North American deaths.

“Problems with these ‘now I love you, now I don’t’ vessels begin when their victims are young. Varying degrees of vessel obstruction can be found in virtually every adult, having begun in adolescence and increasing with age.

“An individual myocardial infarction (heart attack)involves that part of the heart muscle wall supplied by the particular coronary artery that is occluded (blocked), usually measuring two or three square inches in surface area.

“The culprit about half the time is the left anterior descending artery. Half of all infarctions thus involve the front wall of the left ventricle. The right coronary artery, supplying the back wall of the heart, accounts for 30% of occlusions; the left circumflex coronary artery, supplying the lateral wall of the heart, contributes about 20% of all heart attacks.

“The left ventricle, the most powerful part of the cardiac pump and the source of the muscular strength nourishing every organ and tissue in the body, is injured in virtually every heart attack.

“When a coronary artery suddenly occludes, a period of acute oxygen deprivation ensues. If this period is long and severe enough that the stunned and bloodless heart muscle cells cannot recover, the pain of angina is replaced by infarction.

“The affected heart muscle tissue goes from the extreme pallor of ischemia to frank death.

“If the area of muscle death is small enough and has not killed the patient by causing electrical abnormality of heart rhythms, the involved heart muscle, now puffy and swollen, will be able to maintain a tenuous hold on existence until, with gradual healing, it is replaced by scar tissue. (See also: Time Equals Muscle During Women’s Heart Attacks).

“The area of this damaged tissue is incapable of participating in the forceful thrusting of the rest of the myocardium (heart muscle). Each time a person recovers from a heart attack of any size, he/she has lost a little more muscle to the increasing area of scar tissue, and the power of the ventricle becomes a bit less.

“Coronary occlusions or spasms in smaller branches of the main vessels may give few signals to announce themselves, but they continue to diminish the force of cardiac contraction. Thus it is the chronic disease of heart failure, and not the sudden cardiac arrest, that carries off about 40% of victims of coronary artery disease.

“But the heart is far more than just another stolidly stupid pump, but a responsive dynamic participant in life, capable of adaptation, accommodation, and sometimes even repair.

“Back in 1772, a properly designed exercise program to rebuild the heart’s ability to function was described like this by one observer:

“I know of one who set himself a task of sawing wood for half an hour each day, and was thus nearly cured of heart disease.”

“Although the handsaw has been now replaced by the treadmill, the principle is the same.

“A wide variety of cardiac medications are also available now to help the heart muscle and its conduction system. There are even drugs used within the first few hours of an occlusion to dissolve a brand new clot. There are drugs to decrease myocardial irritability, prevent spasm, dilate arteries, strengthen the heartbeat, diminish accelerations of heart rate, drive out excessive loads of water and salt, slow down clotting, decrease cholesterol levels in blood, lower blood pressure, allay anxiety – and every one of them carries with it the possibility of undesirable side effects.”

And there are, as Dr. Nuland described them, “the wizardries of technology” that allow cardiologists to:

  • reroute blood around obstructions in coronary arteries (bypass surgery)
  • widen narrowed vessels with balloons and stainless steel stents
  • replace or repair malfunctioning heart valves
  • zap wonky electrical circuits in those who skip beats (heart arrhythmia)
  • have the whole heart chucked out and replaced with a healthy secondhand one (heart transplant)

All of these procedures, he said, have high rates of success, when the candidate is carefully chosen.

   “And yet, after each one, the process of atherosclerosis continues to lick at life. Widened arteries frequently plug up again, grafted vessels develop occlusions, and ischemia symptoms too often return to their old myocardial haunts.”

And there’s the rub, my heart sisters: like all heart attack survivors, I do, alas, now live with a chronic and progressive disease diagnosis. See also: The Cure Myth

They can patch me up with invasive procedures, prescribe drugs to alter my heart rate, arterial flexibility or blood composition, pat me on the head and wish me well – yet in spite of those wizardries of technology, it’s a fair bet that at some point, I’ll be saying: ‘Hello again!‘ to the Coronary Intensive Care unit staff in our cardiac hospital. We know, after all, that a significant risk factor for having a heart attack is having already had one.

I’ll leave the last profound words on death and dying to Dr. Nuland:

    “Nature has a job to do. It does its job by the method most suited to each person. It has made this one susceptible to heart disease, and that one to stroke, and yet another to cancer, some after a long time on this earth and some after a time much too brief.

“Death is not only the ‘way of all flesh’ but the way of all life, and it has its own plans for us. Though we find clever ways to delay, there is no way to undo those plans.”

And right now, my own plans are to head out the door to walk along the ocean in the sunshine so I can contemplate LIFE for a while. . .

♥

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Carolyn’s Note:  Dr. Sherwin Nuland died of prostate cancer at the age of 83 on March 4, 2014 in his Connecticut home. His daughter recalled that he had told her he wasn’t ready for death because he loved life:  “I’m not scared of dying, but I’ve built such a beautiful life, and I’m not ready to leave it.”

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Q: Since your own diagnosis, have you thought about death more or less often than you ever did before?

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CAROLYN’S UPDATE:  I wrote more about the D-word in my book “A Woman’s Guide to Living with Heart Disease“ (Johns Hopkins University Press). You can ask for it at your local library or neighbourhood bookshop (please support your favourite independenet booksellers) or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from my publisher, Johns Hopkins University Press (use their code HTWN to save 30% off the list price). 

See also:

Heart disease: women’s #1 cause of untimely death

As if fear of dying weren’t bad enough . . .

The most dangerous kind of coronary artery blockage

The Patient Dignity Question meets the “Care Effect”

Published by Carolyn Thomas

17 thoughts on “Deep thoughts about death and heart disease”

  1. I appreciate reading this blog because I have been in a state of not knowing what to expect now that I’ve had a LAD 100% occluded heart attack. The doctor and his PA are vague about my prognosis.

    Reading about how death is where we are headed actually helped, because even though I knew that of course the way she expressed this in view of those of us women who have had a heart attack. I’m looking forward to reading more about other women’s experiences with heart attack.

    I’m thinking now that another heart attack is likely and each one leaving me a bit worse off. Also that I probably will now not make it to my former goal of 100.
    Sandra

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    1. Hello Sandra – you may be correct (about not making it to 100) but you may also be quite wrong. There’s simply no way to predict, so it’s not usually an attainable goal, statistically speaking. And it’s less about meeting a goal, and more about – what are we planning to do with the time any of us have left between now and that 100th birthday party?

      When you say “death is where we’re headed”, you are of course speaking the truth about 100% of all human beings alive on earth today, whether they’re heart patients or not. We *might* have another heart attack, but many many people don’t ever have more than the original cardiac event – particularly if they get serious about adopting heart-smart lifestyle decisions.

      Hope you enjoy reading lots more while you’re here… Best of luck to you.

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  2. This post and going to a recent family funeral (husband’s aunt who died after a long battle with cancer, leaving my mother-in-law the last still living of 14 siblings) has only added to my feelings of wanting and needing to talk with my own family about death and what we all hope for or want at the end of our lives.

    The funeral had nothing to do with the aunt. The minister didn’t know her at all and I wonder how he was chosen, given that none of her three children’s families go to any church at all. It was one of the worst funerals I have been to for many reasons, but primarily because it just went through the motions and didn’t reflect the personality of this vibrant and much-beloved aunt at all.

    I so agree with what was said here about living in a death-denying society and the terminology that is generally used to speak of death (the one I hate is when someone says someone “passed”). When I was in college in the late 70s, I took a health class called “Death and Dying: Implications for Growth” that was very popular on campus. The class was developed by a professor who was left totally unprepared when his daughter died unexpectedly (not sure what the cause of death was). As he struggled to cope with the loss, he began to research the topic and then created the class. I remember that we read Kubler-Ross’ book (On Death and Dying –– I think that’s the title) and an autobiography by a woman who became a widow and had no idea how to get along since her husband had taken care of everything in their lives, especially finances.

    We talked about funeral practices and toured a funeral home, and got to see someone’s “cremains.” Changing views of death over the last few hundred years are even reflected in epitaphs — in times past when death was really more a part of life, people would write little poems on tombstones in remembrance of their loved ones, but nowadays we just give names and dates with nothing to describe what the deceased was like. It’s interesting to me that I should remember so much about that one class when I’ve forgotten so much about a lot of others that I took. It was pretty eye-opening.

    Having heart disease (I have 2 stents, both in the LAD) definitely forced me to face my own mortality in a way I never had before. I’ve thought a lot about the things I want to make sure I say to my children before I die and the conversations about death I want to have with them. I definitely don’t want my funeral to be like that aunt’s, or sad — I want it to be a total celebration of my life and of my “house-warming party” in Heaven!

    Thanks for this post and for telling us about this book, Carolyn, I will put it on my to-read list!

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    1. Thanks for sharing that story of your aunt’s funeral, Meghan. I’ve been to some like that, too (including my father-in-law’s, where the minister – who knew nothing whatsoever about the deceased – delivered a canned speech that sounded like blahblahblah. Not a shred of humanity or effort!)

      I think everybody should be able to take the college class you took back in the 70s!!!

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  3. I like your plan about heading out the door and having a walk near the ocean, embracing life and all it has to offer. Death is always in the back of my mind after having a “widow maker” heart attack at the age of 50.

    That was 15 years ago and every major decision I make is based on the fact that I may not have much longer to live. I like Dr. Nuland’s way of putting it that “nature has a job to do”.

    Meanwhile I believe I will enjoy mother nature and plan to take that walk someday soon near the ocean. Enjoy Carolyn and thank you for your thoughts and profound insight.

    Your blog is the best on the web.
    Thank you.

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    1. Thanks so much for your kind words, Chris.

      Personally, I try to walk by the ocean (or just sit on a log looking at the ocean if I’m not feeling well) every day. I’m thinking of giving myself a shiny sparkly sticker for every day I manage to do this, instead of my current award system: a sticker on my exercise calendar for every day I exercise. Not nearly as good for the soul as a walk by the ocean, I think.

      I hope you get your walk by the ocean soon…

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    2. Yes, I relate to the idea of enjoying the ‘now ‘ by taking a walk along the beach. My family doesn’t want to talk about or think about death.

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  4. Great post (as always) Carolyn,

    I laughed, once again, at your words about dying in your sleep surrounded by a tidy apartment.

    I used to think that but now I either don’t care if people think I’m a slob and/or don’t have the energy to clean up. I’m thinking about leaving things like open journals, sexy underwear and bottles of open liqueur strewn around so that those who find me wonder for the rest of their lives what I’ve been up to they didn’t know about.

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    1. I hasten to add here that this tidy-up-before-bedtime obsession only lasted a year or so (but hey! the place had never looked so good!)

      Eventually I was simply too exhausted to even think about dragging the vacuum out every evening, and besides – I hadn’t died yet! All that tidying for nothing!

      And lately (because of some major furniture moving and other projects, I have had cardboard boxes of packed-up stuff piled in almost every room, each pile waiting for space to open up in another room before it can be moved and unpacked. It’s chaos around here. Whatever… I have created a nice path between the boxes leading directly to bed so I can at least find that at the end of each day!

      I shall consider your excellent suggestion, however, of leaving open liquor bottles and draping sexy underwear on top of the boxes… Thanks Judy-Judith!

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  6. Wow! This is such a profound post. It shines a light on the “mechanics” of cardiovascular disease without all of the confusing medical jargon. For me, it just clarified so much even though I’m 3 1/2 years post widow maker. Stating the process that matter-of-factly is actually a relief. Thank you so much for sharing this.

    I look forward to your post every week. It’s the only heart health-related thing I have been interested in following. I have tried various support systems and frankly got tired of all of the whining and negativity. I appreciate your candor and practicality. Keep up the good work. It is appreciated.

    (I confess that I love your expression “wee lie down” and have found myself using it from time to time.) 😊

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    1. Thanks, Inge – I think you’ve hit upon an important point: it’s that mechanical matter-of-fact way that Dr. Nuland described death caused by heart disease that somehow makes it seem almost plain and stripped of all emotion. Thanks also for your kind words about my blog. Now go have a wee lie-down… 😉

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      1. Matter of fact it’s comforting in the oddest way. One of my relatives after my heart “event” (I really hate that term – sounds like a party and it certainly was not) said to me, “Can we discuss the elephant in the room or is it going to upset you?” The elephant being the possibility of death in the near future.

        Having talked about how we both felt it was strangely calming, oddly uplifting and a very honest discussion.

        Her husband is an ambulance paramedic; spare a thought for the people who are our first line of treatment/help – they don’t go home at the end of a shift and forget us; we impact on them, and their families, in ways we don’t suspect.

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        1. Well, bless your relative’s heart for bringing that elephant into the open. That was a real gift to you, Lindsay…

          Excellent point about the paramedics. I have a number of them who subscribe to my blog and often leave comments in response to my various articles. One in particular I will never forget (Hello Bill Mapes from Vermont!) who wrote me one day after reading here about women heart patients being more likely to be dismissed by Emergency Room gatekeepers. He said: Seldom does an article freeze me like this one did. As an experienced paramedic and EMS Educator, I am big enough to admit I may have been part of the problem. No more… it stops today.” Bill actually changed the way he trains new paramedics. That was the first time the impact real patients have that you mentioned was brought to my attention in a very dramatic fashion.

          PS Re heart “event”: I agree 100%, with one exception that you might find interesting: whenever I do my “Heart-Smart Women” public talks, I’m sometimes accused by at least one woman in the audience of focusing too much on heart attacks and not enough on _____ (insert the specific cardiac diagnosis the accuser is living with!) So I consciously began saying things like, “After a diagnosis of heart attack or a heart arrhythmia or a valve problem or a congenital defect or heart failure or . . .” As you can imagine, these bulky lists slowed down my presentations considerably, so I finally started inserting “cardiac event” as a shorter substitute for a long list of all possible options!

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