Dying in character: the myth of the impish chuckle

You know the joke about the king's close friend, convicted of a terrible crime, who was granted the boon of choosing just how he would die -- and asked to die of old age.

It's a bit ghoulish, but most of us who work in hospitals end upwith lists, formal or informal, of the ways we'd like to die. You can't work that close to death without coming to some accommodation, however uneasy: O.K., I have to die eventually, and I'm not looking forward to it -- but this kind of death, and not that kind, please.

When I was a medical student, the choice was almost always a quick and catastrophic heart at- tack. Drop dead in your tracks, out of the hospital. No chance of resuscitation, no half-life in the intensive care unit. Go from being well to being -- well, whatever it is that comes after.

When you start to think about death, especially with the extra knowledge you get from the hospi- tal, you realize there are the fantasy deaths, and then there are the reality deaths. True, you may not actively fantasize about dying, but there are comforting images that attach to death and beautify it, even sanctify it. One common fantasy is to die in your own home, peaceful and comfortable, surrounded by the people you love best. Gently, you breathe your last breath. My own sensibility was highly affected by certain series of girls' books -- the Anne of Green Gables series, for example. In those books, set in rural Canada at the turn of the century, death scenes were fairly common. Women regularly watched at deathbeds, old sailors went out with the morning tide. In Emily's Quest, the third in the Emily series (by Lucy Maud Montgomery, also author of the Anne books), the title character goes to the deathbed of the elderly teacher she loves. Her aunt explains to her, '' 'He is old and tired. His wife has gone -- they will not give him the school another year. His old age would be very lonely. Death is his best friend.' ''

And so Emily, who is of course a budding writer, bends over the dying Mr. Carpenter, who has a last message for her but can't quite remember it:

''As Emily bent over him the keen, shaggy-browed eyes opened forthe last time. Mr. Carpenter essayed a wink but could not compass it.''

'' 'I've -- thought of it,' he whispered. 'Beware -- of -- italics.' ''

''Was there a little impish chuckle at the end of the words? Aunt Louisa always declared there was. Graceless old Mr. Carpenter had died laughing -- saying something about Italians. Of course he was delirious. But Aunt Louisa always felt it had been a very unedifying deathbed. She was thankful that few such had come in her experience.''

And there it is, perfectly appropriate for a girls' book. No deep wisdom, carefully adjusted by child development specialists to help young people deal with death, just death of a character, dying in character. Blunt and matter-of-fact, but who wouldn't want to die with an impish chuck- le? The point is, in the fantasy, to die in your own home, of old age, and to die in character.

Reality deaths are somethin else again. Death in the hospital israrely serene. And virtually no one gets to die in character.

How do people die? Well, there are a variety of ways. You can die gasping for air, choking to death. That isn't generally considered a desirable death. You can suffer a cardiac arrest in the hospital and die in a code, a crowd of doctors and nurses losing the heroic struggle to keep you alive. You can slip quite peacefully from coma into death -- but who would choose to go out in a coma in the first place? You can bleed to death, which is generally agreed to be a death not too unpleasant for the patient, but horrible for anyone standing near and watching. And so on. You get the idea. It's a gruesome catalogue, but it's an inevitable list to find yourself making when your work involves witnessing many deaths.

So I admit this patient, and she's dying. She's young, but her lung disease is terrible and irreversible, and she's in a lot of pain. Whenever I go in to see her, she asks me to take the pain away, help her die sooner. Both of us know she won't leave the hospital alive. I watch her struggling for each breath, and I find myself thinking, this is not how I would like to die. So I propose to put the patient on a morphine drip, to infuse her with fairly heavy-duty narcotics, keep her comfortable and relatively happy. The only thing is, morphine may depress her respiratory effort, may bring her closer, however gently, to the moment of her death. At first I find this a little hard to deal with emotionally. (In my head are the endless ethical dilemmas of medicine -- would you actually be willing to inject her with poison, and if not, isn't it hypocritical to give her a non-poison that will probably cause her death?) But I find that I'm willing to give the morphine without resolving the dilemma.

Along comes the doctor who has cared for my patient for years. Itell him I'm going to start a morphine drip, and he gets upset. My patient isn't as badly off as all that, he says. If I'd known her for years I'd see that she often has episodes like this -- though never anything nearly this bad. No, says this doctor, no morphine drip. Now of course it's a lot easier for me to contemplate her death, seeing her as she is today, than it is for someone who has known her well, seen her spiral down from healthy to sick. For that doctor, this morphine drip I propose wouldn't be solely a merciful intervention. It would, in all probability mean saying goodbye to someone he has known for a long time.