Amor Fati

{font: times}The smell of the river fills the air, while the sun casts its warm rays on everything below. The sound of the river crashing against rocks and Cormorants cawing in the distance creates a calming ambiance. The sky is painted in hues of blue and grey. and the starting sunset is breathtakingly beautiful as it reflects off the water's surface and is adorned with shades of red, orange, and yellow. Standing on the 300-foot bridge connecting a small island to the mainland, Joseph would ordinarily take in the beauty of nature. Today is different. Today he is grieving.
He is wearing a dark coat and a scarf that covers his neck and mouth. Joseph is a remarkable man, having reached the ripe old age of seventy and despite the physical signs of aging, it's clear that age has not diminished Joseph's spirit or determination.
Joseph walks upright with a cane, has a straight back, and his skin is slightly wrinkled from age. Though old, he is a handsome man with a strong jawline and chiseled features.
Joseph had come here to face the painful reality of losing his childhood friend, Laura. Despite her last wish to be granted a dignified death, in the hospital ICU, her wishes were unfulfilled, and she died in a way that was far from what she had wanted. Her tragic passing has left Joseph devastated and struggling to come to terms with her loss.
As he grieves this "bad" hospital ICU death, Joseph must find ways to make sense of such a difficult situation and learn how to heal from the emotional pain. He had accepted her death but held anger with her wishes not being carried out. Laura's old friend Carol is a legal advocate for a large-right-to-die organization and became involved with getting Laura's final wishes accepted by the health industry. He wanted help from this meeting with Carol to release his resentments.
Turning a bend in the forest, he sees the small hut where he is to meet Carol. She has already arrived and waves a greeting.
"Greetings Joseph, it makes my eyes happy to see you."
Joseph can't help but feel at ease seeing Carol in this setting.
"Yes, and you, beautiful Child of God. We last met under happier circumstances, didn't we?"
"We were three then, now we are two.
Throughout his life Joseph has learned patience, However, today he is anxious and emotionally invested to learn the worst. Direct into the points asks, "Well Carol, bring me up to speed, tell me what you know."
"Six months ago, I took on the position of end-of-life advocate. A month ago, on the 30th, I received a call from Laura's husband, Bob, who was her Medical Power of Attorney."
"Yes, Laura told me about that. She said Bob agreed with what she had outlined. I thought it was a good choice."
"Well, it didn't work out that way. Laura was admitted to a large teaching hospital. Doctors did not respect Bob as her Health Care - Power of Attorney and were not following her Advance Directives. Bob wanted my help. She has endured continual pain for the last seven months while recuperating from three surgeries."
Joseph frowned, "But she has made her wishes about the end of her life unmistakable. We've talked over them on numerous occasions: no more medical procedures, Ventilators, force-feeding, antibiotics, or revival attempts."
Carol nods, "I understand what you're saying, but like I said, it didn't work out that way. A few weeks ago, Laura was moved by her surgeon for a procedure requiring intubation. During the 8-hour operation, they found a blood clot and assumed that some of her intestines had passed away.
Her state of health was severe and she was being monitored constantly. On the second day, she was removed from intubation and on the third, she had already started her physical therapy sessions even though it caused her considerable agony."
Josephs's eyes narrowed, "What is Bob up to at this point?"
"He changed her Do Not Resuscitate and Physician Orders for Life-Sustaining-Treatment right away, to reflect that she should only receive comfort-oriented treatment instead of resuscitation."
"Sounds like he is involved?"
"The pain was getting worse for her, so the doctors decided to take away food & medication without asking permission to help her digestive system recover, requiring a feeding tube. A PICC line was put in place to provide Laura with nutrition and medicine.
The medical staff assured Bob that she would get better if he kept up the treatment, making Bob feel uneasy yet hesitant to pull the plug. By withdrawing it, her passing was guaranteed."
Two weeks after her initial visit, the surgeon contacted Laura to inform her that she needed emergency surgery to identify the cause of her pain - they thought it could be a dead bowel. Without this procedure, she was at risk of succumbing to sepsis and dying a long, slow death."
Joseph cocking his head and then shaking it, says, "Don't studies show that sepsis can take as little as 12 hours to be fatal without the aid of antibiotics, in contrast to what the surgeon said before. This usually happens without pain or agony."
"That wasn't said. Although she had consented to the surgery, doctors weren't sure she understood, and they wanted Bob's consent. Against his instincts, he agreed. Shortly after, her nurse called and said that when they tried to get her ready for the surgery, she refused and started screaming. So, Bob quickly called the OR to retract his consent."
"Bob sounds unsure of himself. Where did you come in?"
"After I took this job, Laura put my phone number into her directives as a go-to person. Knowing he was in over his head he called me for assistance. After assessing Laura's end-of-life paperwork, I concluded that Bob had the authority to make medical decisions on her behalf. I suggest that Bob consult Palliative Care and get in touch with the Ethics Committee.
Shortly afterward, both the operating and attending surgeons asked Bob to approve two possible surgeries during a phone conference. "
"This is starting to sound insane."
" The Technical Surgeon said the issue was solvable and wanted to take a look. However, the other surgeon refused to agree. Despite that, the treating doctor wouldn't accept 'no' as an answer and discussed potential treatment plans while trying to make their case.
He enforced the importance of his statement by making it clear that he would not succumb to extreme dosing of painkillers to allow her death or shift her to hospice.
To put an end to the conversation, the anesthesiologist mentioned that they had been involved in Laura's last three surgeries and she wouldn't approve of it. Consequently, they agreed to move Laura into palliative care without any surgery."
"Well, now they seem to be moving in the right direction."."
"Yes, it would appear that way. But don't get too far ahead of the story. That night, the AS phoned Bob and commented, "I believe we made the correct call.
Bob and I were confused since she had been pushing for surgery right up until the day before. The next day, she contacted me to inform me that the surgeon had managed to convince Laura to proceed with the operation despite the attending physician not believing her to be legally competent enough to make such a decision."
Joseph raises his eyebrows, "Damn! Just what I thought we were on the right path."
"Bob demanded a call from the TS. While I listened in, he once again pleaded for surgery. He had an answer for every question and objection Bob had regarding potential bad outcomes.
He refused to transfer her to hospice care, but Bob reiterated that Laura didn't want any more treatments. Finally, he consented and brought in Palliative Care."
Carol continued, "Bob phoned me to report during his conversation with the palliative care unit, he was given a comprehensive response with no hesitation. They emphasized that he had authority over all decisions.
They completely agreed with my suggestion for Bob to take control of the situation and discontinue the antibiotics and nutrition right away, reinforcing her declaration of his authority."
"So palliative care comes in on our side of the question."
"In the end, PC had to take action and decide on a plan of treatment for Laura because the medical team was still discussing if hospice was the right option.
A sudden gust of wind caused their conversation to pause for a moment, but they soon continued talking as if nothing had happened. The cold wind was a reminder of the harsh autumn that was upon them, but it also brought with it an opportunity for Joseph and Carol to weaken their pain and appreciate the beauty of nature and the moment they were sharing.
Carol says, "Bob visited her the next day; she was relieved to see him and said that she could now be able to enroll in a hospice. To make sure she was comfortable, Bob fought for the right amount of medication which eventually worked. After six days at the hospice, she passed away peacefully."
"You tell of a bad trip to get to the place where she should have started."
Carol pauses before speaking, "Bob was having a difficult time getting help for Laura. He had encountered doctors who had their agenda, were not willing to listen, and even gave conflicting advice.
These were not evil people. The surgeon tried to make her better with treatments & surgery so she could still go on with her life, instead of sending her to hospice he continued pushing medical procedures.
Laura was not in the right frame of mind to comprehend the gravity of her situation and so wasn't able to understand what the doctors asked her or what undergoing surgery would entail."
Joseph sniffing, wiping his nose, an empty stare in his eyes says, "Why didn't Bob do more -- faster?
"Bob experienced a great deal of emotional turmoil during this time. He neglected her advocacy, subject to force & coercion, and was sad about his wife's deteriorating health. His emotions ran the gamut from anger & frustration to puzzlement & internal conflict.
Bob expressed how grateful he was to Palliative Care after their conversation and said that they provided comfort like the advice given by me. He acknowledged that I have been of great help.
Bob was confident that he could be an effective advocate but faced various obstacles. Throughout the process, a nurse and two doctors said to him "If it were my turn, I'd want someone like you as my advocate". This reassured & encouraged him and it meant the world to him that he had support."
Carol becomes silent. Joseph stares blankly off into space. She has reported all she can recall to Joseph as objectively as possible. She recognizes that Joseph has accepted Laura's death; however, he still has an emotional attachment to how she died. With a heavy heart, she shrugged her shoulders in resignation and reached out to him one last time in an embrace. With sadness in her eyes, she then turned away and left the hut.
He soon follows, and as he walks along the river's edge, he can feel his anxiety lessen and a sense of peace and tranquility that only nature can provide. The stunning sunset is breathtakingly beautiful as it reflects off the water's surface and is adorned with shades of red, orange, and yellow.
He thinks Nature can be a powerful force in restoring peace and tranquility to my mind. This has been a refuge for me when I'm anxious and overwhelmed. I know acceptance is often the first step towards embracing life's challenges, but do I have the courage it takes to embrace what fate has offered? So often I have taken a giant leap of faith and found solace in nature. This meeting on my island with Carol may allow me to not merely bear what is necessary but love it. Amor Fati!
                                                                     -30-