Inspirational

Dying and Living, Perspective of an Intensive Care Physician

By

This book will launch on Mar 8, 2021. Currently, only those with the link can see it. 🔒

Loved it! 😍

This is not your typical medical memoir. Dr. Haake is a well-educated man who has learned from his experience as a patient.

Synopsis

For the third time, I had rescued an Alzheimer’s patient in respiratory failure from death. While rounding in her nursing home, I ran into her husband and expected gratitude and a handshake. Instead, he asked to be called the next time she decompensated. Keeping her alive had exhausted all their savings. I assumed falsely code status had been previously discussed and he had wanted “everything done”. She was a human being with a terminal disease. She was curled up in a ball from muscle contractures, and a feeding tube had been placed to keep her alive. Each time she was stimulated, she screamed…. What the hell was I doing?
This book details the evolution of an intensive care physician who thought he cared. I came to realize I had little understanding of how people died. I came to understand that no one else did either. A thousand bedside end of life discussions plus my own near death experience with cancer, gave me a unique insight into the process of dying. That experience with dying formed the basis and the connection with living as well. As there is generally no plan for dying, there is seldom a plan for living.

This book is not what I expected - it's not just a memoir of a physician who has been a patient. Expect wide-ranging treatises on historical figures, philosophers, war, mathematics, earth, and space. There is no classic Near Death Experience (you know - tunnel, bright light, life review), as the description would imply.


What the reader can expect is an articulate, if far-ranging, memoir of a thoughtful man who happens to be a medical doctor. Dr. Haake shares his insights as a critical care physician, on end-of-life decisions and their ramifications for the dying, their families, and society at large. Having recently buried my mother (and less recently, my father), I grasped his meaning well - and I think any other reader would be able to do the same.


I believe the author to be compassionate and thoughtful; he is clearly someone whose goal is to do the right thing - to strive to be his best self. This is an interesting concept when juxtaposed against his belief (which I am greatly simplifying) that dying patients and their families need to do the opposite - to stop striving. I happen to agree with both points of view and I think they can coexist.


Dr. Haake is an intelligent man and a good writer. Overall, his worldview as demonstrated in this book is Western and traditional. All of the historical figures he references are white males, and he expresses sympathy for the female physician who might have to work so hard that she won't have time to find a mate and might not ever "have it all," which I consider to be outmoded thinking. However, Dr Haake also writes about his cancer treatment at the hands of female physicians with complete lack of prejudice.


I recommend this book to anyone who has an interest in our society's handling of end of life care. If you've experienced a recent loss though, be aware that this could be a tougher read.











Reviewed by

I am a reader with ten years of bookselling experience who is passionate about sharing my love of books with others. My goal is to be direct and relatable, with hopefully a little humor thrown in.

Synopsis

For the third time, I had rescued an Alzheimer’s patient in respiratory failure from death. While rounding in her nursing home, I ran into her husband and expected gratitude and a handshake. Instead, he asked to be called the next time she decompensated. Keeping her alive had exhausted all their savings. I assumed falsely code status had been previously discussed and he had wanted “everything done”. She was a human being with a terminal disease. She was curled up in a ball from muscle contractures, and a feeding tube had been placed to keep her alive. Each time she was stimulated, she screamed…. What the hell was I doing?
This book details the evolution of an intensive care physician who thought he cared. I came to realize I had little understanding of how people died. I came to understand that no one else did either. A thousand bedside end of life discussions plus my own near death experience with cancer, gave me a unique insight into the process of dying. That experience with dying formed the basis and the connection with living as well. As there is generally no plan for dying, there is seldom a plan for living.

I. DYING

Chapter 1. Family History

Grandma died in 1974 at the age of 84. Four out of five of her sons still lived in Germantown, Illinois. Her family lived in a two-story rectangular Federal-style home that doubled as a living quarters on the second floor and a tavern on the first. Like most homes of the early 20th century, it was devoid of the impractical add-ons such as gables and arches that are designed to impress family or friends, and featured only the essentials of doors, windows, and a tin roof. The bedrooms upstairs were for the kids, who could not escape a slow roasting in the summer nor the frigid leaks around the windows in the wintertime. Half a century before, her aunt had six children who froze to death on a hearth by the fireplace. The home was across the street from St. Boniface Catholic Church, where the kids attended church and school, and discipline was discharged in double doses: a beatin’ at school and a beatin’ at home for getting a beatin’ at school.

My grandfather, Joseph, died in 1938 of pneumonia. My dad was 18. His recollection years later was no longer somber and with interested reflection he reports that, on the day of his death, heavy, desperate breathing could be heard all over the house as his father struggled to satisfy an unrelenting air hunger in his last hours. He was attended by the local physician, who lived by a paucity of certainties except his own powerlessness to favorably alter the course of virulent community-acquired pneumonia. The black bag he carried fraudulently portrayed the hope for comfort and a cure. His tools were simply diagnostic, and his remedies were homespun potions and gimmicks born out of the pharmacology of years of wishful thinking and an absence of immediate death when “medicine” was administered. They were at the very least substantially less poisonous than medicines used seventy years before in the Civil War.

The physician merited a fee for service because of his prognostication expertise. Having attended a generation of dying patients, he sensed death. His conclusions were not developed out of a summation of fact and the compilation of lab values and X-ray reports. He recognized that final inert facial expression witnessed as the spirit is gently liberated from the body. He understood the irrevocable progression of rapid pneumonia-induced respirations to those final despondent, agonal respirations measured in the single digits. Where most can detect an unfamiliar aroma, he identified the olfactory culmination of bacterial infection and organic necrosis as the imminence of death.

My father still recalls the remarkably primitive opinion of the doctor after his exam of my grandfather. It was a familiar verdict heard frequently in association with the diagnosis of pneumonia: “If he lives the next 10 to 12 days, then he’ll likely survive.” My grandfather died within 10 days.

Today, we give solemn reflection to the “frailty” of life when we read about or know of someone by distant association who experiences tragedy. Our experience is relative to the rare occurrence of an incurable malignancy or a fatal accident. Within 6 weeks of my grandfather’s death, his 20-year-old daughter passed away. My father believes she weighed 35 pounds at her death.

She had been losing weight since the age of 13. Prior to these adolescent years, her leg speed and baseball skills rivaled those of most girls and some boys. Years later, Grandma confided to my father that Ruth “thought she was fat.” Local physicians were perplexed by her malady. No one in Germantown had seen or experienced such a wasting illness and complete loss of appetite. The pain of this distressing illness was magnified by her delusion of obesity. In those days, this made her mental competence suspect, as mental illness was not fully understood and was seen as disgraceful. The reason was, relative to other disabling and lethal diseases, a mental illness was seen simply as an incapacity to control simple behaviors. Phobias, paranoia, and depression were inconsistent with common emotional experiences that everyone else seemed able to manage. It was considered a weakness worthy of derision. Treatment was generally limited to the likes of a “Thanks! I needed that!” slap in the face. There was no political correctness in the 1930s, and there was no need to put a delicate spin on this contemptible loss of control—especially within the context of people dying of “real” diseases. When the patients became uncontrollable, they were “hauled down to the nut house” rather than admitted for psychiatric counseling. Not surprisingly, Ruth’s perception of herself was kept secret for many years.

Doctors were considered “smarter” up north, which, in Illinois at that time, was Springfield and then Chicago. In their quest for a diagnosis and possible treatment, Ruth and her father made this very long journey. Their troubled pleas were only met with more puzzled faces. Ruth was taken home without the hope of a cure. At the end, she was able to eat only crackers and some fluids. She died at home surrounded by her family. She had classic symptoms of anorexia nervosa.

I toured the cemetery with my father before he died. I was struck by the close proximity of Ruth and Joe’s graves. It was only then that I discovered the temporal relationship of their deaths. It is difficult to imagine the depth of the family’s grief at that time. I imagined the family huddled around the grave on that blustery February morning in their blackness within an upward glance at the recently attended grave of my grandfather. Frozen, dissipating chunks of dirt now clinging to the side of that settling mound: a haunting reminder to my grandmother that no one was safe. She remained at the mercy of a God who gave no guarantees and was within His right and His will to again challenge her strength and her faith.

Grandma’s oldest son, Dominic, was “different.” In the simmering twilight of the summer, when adolescent boys boxed under the street lamps, Dominic preferred reading. He wasn’t very good at baseball in a town where the game was played with zealous intensity, once or twice daily in the summer, organized by the kids, and disbanded after several innings in a flurry of fists or an angry exchange: “He was out!” “He was safe!” “I quit!” “You quit, we win!”

Dominic was a gentle boy. Unlike most of his peers, he lacked the aggressiveness to throw a punch at the slightest affront. Dominic wanted to be a priest, but the family, like most, was poor. They lacked the resources to send him to the seminary. According to my father, he wasn’t equipped for hard manual labor. I presume it was because of his stature. After high school, my father worked in a quarry, worked in a smelter, and worked for the Civilian Conservation Corps. Dominic looked for a different line of work, and the opportunity arose when a local resident came home from Chicago on a Christmas visit. She worked at St. Ann’s Hospital, and there were orderly jobs available in that hospital. Dominic became an orderly on a tuberculosis ward.

The family struggled in those years of the late 1930s. Jobs were scarce, but most families were large, and they worked as a team to bring in enough money to buy food and clothing. The standards to be a member of the middle class were pretty low. As my father puts it, “We were poor, but didn’t know it.” Carrying a few extra pounds on your frame was considered attractive, as it represented prosperity. In the same way, real destitution was more than the realities of poverty. In the ’30s, it also came with guilt. In the mindset of that time, hard times and poverty were deserved. Not only were you an object of derision, but you felt personal guilt for your predicament. The sanctuary of being a victim was not yet born in the minds of the disenfranchised.

Nothing was taken for granted. The communal experience of untimely life lost added depth to their celebrations. Prayers at bedtime were spoken in earnest because there was real gratitude for another day lived when life was so fragile. A hot meal was savored because the specter of hunger stalked the shadows in the world around them. “Skinny” wasn’t a choice for many, but a natural consequence of a chronic inadequate caloric intake.

Later in the ’30s, war loomed in Europe. Word of the conflict in Europe trickled down slowly to this small community in southern Illinois through the St. Louis Post-Dispatch and the radio. Historically speaking, there was an isolationist sentiment in the United States, but according to my father, this was not shared by the people of Germantown. They read between the lines and understood that Hitler had grand designs. If Great Britain was conquered, the United States was at risk.

Joe Haake had four boys of draft age. My father was the first to sign up. I don’t know the nature of his motives. Probably, like most, they were a subconscious collection of anger, duty, and honor. There was likely also a tincture of adventure and opportunity with a pinch of boredom.

There was no fanfare at his departure. He said simple goodbyes to his younger brothers and sister, and no one knew when they would see him again. Others were also leaving, and fear permeated the community. The collective memory of those with relatives who fought the wars since the Civil War knew that this was not an avenue to fame and adventure. Celebrations at departure implied a short war and a glorious victory. The wisdom of the older generation knew that this was a fantasy. Fame and glory were ephemeral ambitions and unrealistic, but still projected by the military superstructure to implement a war that had to be won.

In August of 1942, my father hitchhiked to St. Louis. He had received his draft notice but had an opportunity to join one of the other services before official induction into the Army, and initially intended to take this opportunity. He considered joining the Marines, captured by the poster promotion “first to fight.” He had second thoughts on the way.

“First to fight” could also mean first to die. He planned to talk to the Navy recruiter first, but he was out to lunch. The Marine Corps recruiter was standing in the doorway in his dress blues: fit, tall, confident, and smiling. It was an immediate mismatch. The recruiter had seen hundreds of boys just like him: unsure, naive, honest, with a dearth of street smarts. Since lying was an automatic “beatin’” at home, it was inconceivable that someone could look you in the eye and not tell the whole truth. The recruiter informed my father of Marine Corps traditions and reiterated that the Marines were indeed the first to fight. My father was asked what kind of work he wanted to do in the Corps. He replied that he drove a beer truck for his father, and truck driver seemed best suited for him.

“When you’re out of boot camp and they ask who wants to drive a truck, just raise your hand,” the recruiter told Dad. Driving a truck likely wasn’t in the front lines and should keep him out of harm’s way. The Marine Corps seemed like a pretty good outfit. You apparently have the power to manage your own risk. If being a hero is important to you, then you can select the more dangerous jobs. If you want to serve but not get killed, then truck driver will do just fine.

At the end of boot camp, of 300 men in 5 different platoons, 1 went into the Marine Air Corps, 5 “Texans” were designated as cooks (“couldn’t hike and had flat feet”), and the rest would be a line company in the Third Marine Division. “Line company” meant front line, infantry, first to fight. Being a truck driver was never an option.

My father did not return home and was sent directly by train to Camp Pendleton, north of San Diego. In early August of 1942, about the time Dad started boot camp, the First Marine Division was invading Guadalcanal. In late 1941 and early 1942, after Pearl Harbor, the Japanese war machine had expanded their dominion southward to include Indonesia and the Philippines. Intelligence reports also indicated that a Japanese construction brigade was building an airstrip on the island of Guadalcanal. This small island was less than 500 miles northeast of Australia and threatened direct invasion of this nation and New Zealand. Australia and New Zealand were defenseless. Their armies were already engaged with the Germans in North Africa.

There was an urgency about stopping the southern thrust of the apparently indomitable Japanese army. America was unprepared for war, and it took eight months to put together a fighting force capable of taking on the Japanese. This became the job and, ultimately, the legacy of the United States Marine Corps. The prospect of a conflict with Japan had been anticipated and discussed since the early 1920s. The Marine Corps was groomed as an amphibious fighting force capable of disembarking from large ships to smaller landing craft, storming beaches under heavy fire, and fighting in close quarters under horrific conditions.

The battle of Guadalcanal raged for six months as it became a magnet for the Japanese Navy and Japanese Army replacements. The Japanese were initially surprised at the bold invasion of this island, as they had little exposure to Europeans or Americans due to a closed militaristic society with rigidly enforced thought control. Americans were considered weak and materialistic, and this was taken as irrefutable dogma by the combatants. The surrender at Corregidor did nothing to dissuade them from this perception. The heavy fighting on Guadalcanal soon imbued a general contempt for Americans.

The Marines were dumped on this island with limited supplies. A subsequent naval battle forced the Navy to withdraw, effectively abandoning the Marines to their own ingenuity and fearlessness to stay alive. Rations were cut, and captured Japanese supplies supplemented their meager diets. The Japanese were determined to drive the Marines from their island. Out of these desperate engagements over many months, between two radically different cultures, rose the mythical dimensions of the United States Marine. The Marines fought valiantly in the putrid jungles and disease-infested swamps of Guadalcanal and did so with such aggressive tenacity that they redefined the essence of a modern-day warrior. They gave the Japanese their first land-based defeat of the war, and organized hostilities ended February 9,1943.

Around this time, my father finished boot camp and was shipped out. His first stop was New Zealand for additional training and then on to Guadalcanal for a “mop-up” assignment. Patrols would still encounter small groups of Japanese, and firefights were not uncommon. The Japanese still had air superiority, and dodging bombs during air raids was another occupational hazard on this island. He caught his first case of malaria on Guadalcanal.

The Third Marine Division’s first major engagement was an island at the opposite end of the Solomon chain, Bougainville. The grand strategy was to island hop in the South Pacific, creating airstrips along the way, ever closer to the Japanese mainland.

My father’s recollection of this island campaign seventy-five years later remains vivid in many aspects. In some areas, there is scant memory of details. They landed in high pounding surf and heavy resistance from the Japanese. My father was on the first wave to hit the beach. Many lost their lives either drowning or being smashed by the Higgins boat landing crafts. They landed in a swamp and were ultimately able to penetrate into the jungle that first night. The Higgins boats became hung up on the reef in the pounding surf and were not able to be withdrawn. Resupply, therefore, was dependent on a specialized vehicle called an “amtrac,” of which they only had a few. They landed with only two days’ rations in their pack. After several days, the Marines did indeed run out of food. Their diet then became dependent on rations from dead Japanese, which were almost exclusively canned salmon. The Marines claimed they could smell the Japanese before they could see them. They speculated it was the salmon.

The most common recollection of the Marine on this island seems to be the misery of the jungle. It was hot during the daytime, as this island was close to the equator. The jungle was infested with a competing army of ticks, lice, sandflies, fleas, and a various assortment of flies—all of which, as my father recounts, “drew blood.” They also left a souvenir of yellow fever, malaria, filariasis, and dengue fever. The stings from spiders, centipedes, and scorpions, though unpleasant, usually were not lethal. The jungle was very dense foliage and overrun with barbed vines, nicknamed “wait-a-minute” vines. Plants of beauty surprised you with a hidden sting. Fire ants cuddled in bright flowers were more than happy to give their lives to inflict one memorable moment of pain before they were crushed under someone’s hand. If you weren’t wet with sweat by four o’clock, you were soon drenched by rain. This then led into night, where a chill led into a dependable drop in temperature and further wretchedness.

At the pre-invasion briefing on the ship, the officers reviewed the many ways you could be killed on Bougainville. In addition to the above and the Japanese Marines, the island was also home to a colony of headhunters.

The Marines attacked during the day, and the Japanese were busy at night. There was little time lost sleeping. In the first week, my father’s company was deployed at an advanced position from the front lines to assess and monitor Japanese troop movements. At night, they dug in and waited. You stayed alive by not giving away your position. This meant absolute silence. If a Japanese fell into your fox hole, orders were to use your knife and not your gun to dispose of these night stalkers. Two companies of Japanese walked within inches of their line that night without incident.

The following night, a firefight did break out with high casualties on both sides. My father reported the incident without much emotion. When questioned about the details of those nights, he states only “it happened too fast.” Like many Marines, I suspect, an act of active repression, details too ghastly on which to ruminate. He does recall a BAR man, so named because he carried a Browning Automatic Rifle, “cracked up” and rushed the Japanese lines with his gun blazing, shouting predictable epithets used by desperate, terrorized Marines before they die. They found his mutilated body the next day. They feared that most of this was done before he died. In their hearts and souls that day, they made a pact; none of them would ever be captured alive.

The Japanese landed reinforcements behind their lines within a few days after their initial landing. The Marines in my father’s company were now caught between two Japanese armies. The Japanese also still had air superiority and continued to menace them from the air with bombing or strafing if they could identify their positions in the jungle. Usually they couldn’t.

In late December, Bougainville was finally declared secure. The Marines were relieved by Army combat units. Forty percent of Company F of the 2nd Battalion, 9th Regiment, Third Marine Division were killed or wounded. My father suffered two bouts of malaria on Bougainville. The “jungle rot” he picked up still tormented him twenty years later.

The Third Marine Division was sent back to Guadalcanal to train for the invasion and recapture of Guam. Nightmares during combat were unusual. Once back in secure areas, however, screams and howls could be heard in the heavy nighttime air as young minds tried to assimilate the realities of combat into their dreams. To maintain sanity, the debt of weeks of sleep deprivation had to be paid back. Under normal circumstances, not necessarily an unpleasant burden. Fresh from a foxhole where an exhausted catnap may be interrupted by someone’s bayonet truly defines a rude awakening, and later, an agonizing intractable nightmare.

On July 21,1944, the Third Marine Division invaded the island of Guam. Guam is the largest of the islands of the Mariana chain. It is 32 miles long and 4 to 8 miles wide. My father was in the third wave of landing vehicles on shore. Again, the Japanese put up heavy resistance on the beach. The terrain again was difficult to negotiate. Thick, tangled jungle and all of its accoutrements again plagued advancement and fostered claustrophobia. Defensive positions by the Japanese were taken up in numerous caves, and the Japanese were rarely extracted from these caves. Capture was dishonorable, and the Japanese typically fought to the death.

In my childhood, “war stories” consisted mainly of the antics of young men, newly liberated from their parents, fully qualified to drink alcohol, and further untamed by the absence of the opposite gender. I heard the stories of the three-day Polish wedding, stealing raisin jack from E Company, sailors looking for Samurai Swords, the “one Marine can beat up three sailors” myth, the naked Marine with dysentery and how he cracked up story, the intoxicated friend who stole a train in New Zealand (and his court martial) story, and the stealing beer from the Army story. But like I stated before, details of combat experiences remained hazy and, in general, my father exhibited a reluctance to revisit these repressed memories.

On a visit home, I came across a book he was reading, The Recapture of Guam. The book was unmarked except the pencil marks at opposite ends of three paragraphs:

Over in the 3rd Marines sector, fighting was even more confused. The 2nd Battalion, 9th Marines, in its exposed position, received the brunt of the Japanese 48th Brigade’s attack. Just when the main push came is hard to tell. Pressure against Lieutenant Colonel Cushman’s units had not let up since they moved onto the slopes leading to the Fonte Plateau in late afternoon. Evacuation of the wounded had been almost impossible and the situation at dusk was none too secure. After an intense day of fighting, ammunition was practically exhausted, and the dribble of supplies carried up the cliff trail could hardly be expected to replace even a third of that already expended.

A platoon of tanks loaded with ammunition was dispatched to the battalion, but darkness settled with no word from this convoy.

Enemy pressure increased as the night wore on and fighting in the 2/9 area became more bitter. Cushman moved his reserve company up to reinforce the position held by the advance assault unit. The right company, driven back in the afternoon, had been reorganized and now guarded the gap between the regiment’s right flank and the 21st Marines. Riflemen had only two clips of ammunition per rifle, and mortar-men reported approximately six rounds per tube available. But still nothing was heard from the supply vehicles. Finally, just as the Japanese launched another strong counterattack, the ammunition-laden tanks came into the position. The vicious fighting in the sector definitely subsided by 0900, but the attack had cost 2/9 over 50 percent casualties. It had, however, resulted in 950 Japanese dead. Seven determined counterattacks had been made by the enemy, but the equally determined men of the 2nd Battalion, 9th Marines had lost no ground.[1]

Fascinated by this account, I questioned my father on his recollection of these events. He indeed had only one clip, or just eight rounds left. “But I had a lot of grenades.” In the morning, he had a bayonet wound in his hand, but everything else “happened too fast.”

During the campaign on Guam, my father sustained white phosphorous burns on his arms. This is an especially memorable injury as the burn cannot be extinguished and must burn itself out. He also caught dengue fever. This viral infection, passed by mosquitoes, manifests itself with temperatures up to 106° and severe pain in the back, muscles, and joints. He claims to have lost consciousness from the fever. He returned to his company after about a week, where he sustained further shrapnel wounds, none of which demanded his evacuation. As my father later reported in a brief synopsis of his wartime experiences, “I never complained about my wounds after seeing my friends lose hands, arms, legs, or their life. I also declined to report my injuries. They needed every man that could fight.”

Organized resistance ended on August 10,1944. My father’s company sustained sixty percent killed or wounded. Total Marine casualties, killed and wounded, were 7,363.

While my grandma’s four sons were overseas, my uncle Dominic contracted tuberculosis. I guess a not-unexpected outcome if you work in a tuberculosis hospital. Health insurance was not one of the benefits, and he was dismissed when he could no longer perform his duties. Never mind the fact that he also had a highly contagious disease.

The closest hospital capable of containing the disease was in St. Louis. My grandma had no resources to pay for a hospitalization. The safety net of the 1940s was large families, some of whom hopefully could find a job. Grandma now had four sons in the service, and all were still alive. All became aware of Dominic’s illness and his predicament. Grandma went to the parish priest and the Red Cross seeking assistance just for the hospitalization. Some assistance was received, and Dominic was hospitalized.

Of greater concern was that Dominic needed an operation to keep him alive. Since the turn of the century, a “thorocoplasty” was offered to patients as a treatment for tuberculosis. For those cavitations created by the indolent but progressive tuberculosis infection, ribs were resected, and that portion of the lung which had been destroyed by the infection was collapsed or “put to rest.” This procedure would bring the chest wall down to the lung and would not expand after the infected material had been drained. The mortality rate for this procedure was thirteen percent. Since there were no antibiotics available at this time, this operation was much better than no procedure at all. My father and his brothers were alerted to the seriousness of Dominic’s condition. Even though they were overseas, they signed affidavits stating that they would accept full responsibility for all medical expenses incurred for the hospitalization and the surgery. This apparently was an inadequate guarantee that the hospital and the doctors would get their money. They refused to perform the operation without payment. Dominic died from complications of tuberculosis.

Back in the Pacific, just twelve Marines in the 2nd Battalion with the rank of private first class had survived three combat campaigns. Five of these twelve were eligible to be sent back to the States for 6 months. My father was one of the twelve who participated in this lottery. Enough combat points during this time did not mean discharge, as all who signed up for the service signed up for the duration of the war. It was still anticipated that the Japanese would not surrender, and ultimately the invasion of the Japanese mainland was expected and being planned. The Third Marine Division had already been assigned Kyoto. My father was one of the lucky five who were sent back to the States. The unlucky seven stayed with the division and prepared for the invasion of Iwo Jima.

Years later, my father and I would sit outside on the patio and drink beer, and he would reflect on the war. Most of the stories were funny. It wasn’t until the last few years that he talked about Iwo Jima. After the first couple times, I figured out why I had not heard these stories in the first 40 years after the war. I think it took 40 years to attenuate the pain.

Each time he talked of Iwo Jima, he cried. It was here that the remnants of his platoon, as he put it, “were all killed.” He ran across other survivors of what was later known as “Cushman’s pocket” at a Ninth Marines reunion many years later. It was here he learned the details of the fight that took his closest friends. It was his understanding that Company F was surrounded and cut off way in front of their own lines. It took more than two days to extricate them from this “pocket,” and not before more than half of them were killed.

I have a picture of my father and his brothers, arm in arm in their military uniforms taken after the war. The ear-to-ear smiles reflect the joy of surviving the war. These stories give dimension to the circumstance of living and dying in this previous generation. They are extraordinary and quite a contrast from our lives today. They add a perspective to “hardship” that has been forgotten.

Grandma died in 1974. In the last year of her life, she could not live by herself and was passed around to each of her sons who lived locally. She stayed one month with each of her children. She wasn’t thrilled with this arrangement, but it was otherwise acceptable to everyone. Her mind was still sharp. She had a good sense of humor and was frequently the focal point of good-natured razzing by too many teenage grandsons. She was 84, and I think intuitively we knew she was ready to close that final chapter. We did pepper her with questions about her childhood and more than once tape-recorded her answers. In the last year of her life, she became intimately involved in the lives of her children and her grandchildren. This is apparent in the letter she wrote me when I was away at college in October, 1971.

Dear Ron,

I received your letter and was glad to hear from you. I don’t know much news. Will try to tell you all I know. I was over at your mom’s and spent Saturday evening with her. She is just fine. Your dad is working. How are you? Haven’t you found a nice girl yet? I think you are cute too. Aunt Francis is all smiles now. They made a priest out of Sister Maxine. She gave out the communion to the people in church. She is stationed in Trenton. What do you think about that? Well Ron, I don’t know much news. I hope you are doing good in school. Are you still playing basketball? Kevin plays basketball. Dale plays football and Lester plays baseball. I don’t know much about sports so I can’t tell you very much. Dan still has something wrong with his legs. I don’t think he can play yet. Buck is working every day. How is Bobby? Tell him hello and be a good boy. I was out to Blanche’s a couple days last week. She is pretty good now. Well I guess I’ll close and go to work. I have lots to do today so bye bye. Hope to see you. I hope you can read this letter. I can hardly read it myself. So good luck.

From Grandma

There was no mention of aches, pains, arthritis, rumors, gossip, scandals, or that almost universal octogenarian complaint of “weak and dizzy.” Grandma could only speak of her children and grandchildren. Grandma was not distracted by her age, her health, her wealth or lack of it, or her regrets. I can’t imagine she had any. Life was simple. She was surrounded by children and grandchildren who loved her, and she loved them in return.

In the spring of the following year, one night we were notified that Grandma had been admitted to the local community hospital. St. Joseph’s Hospital had fewer than 100 beds and likely was never close to capacity. I was born in the old St. Joseph’s in 1950. There were few physicians on staff at that time. Old-school doctors who worked all day and were called all night, delivered babies, watched people die when they got old, and were amazed that their children grew up so fast.

The morning after Grandma was admitted, we were called and informed that she had died. The children and the grandchildren gathered at her bedside. My recollection was that it was peaceful. My impression now is that Grandma was found dead in the morning when the nurse came in to check vital signs.

There was no evidence at the bedside that Grandma had undergone any type of violent intervention that is mandatory for an unexpected attempt at dying in patients without a code status discussion. Grandma was lying there in quiet dignity, with a 22-gauge IV in her wrist. Apparently, she was allowed, of all things, a natural death.

There were no tears at the bedside. The children exchanged informal humorous anecdotes about Grandma. We laughed and thought of a life well lived. Later, still at the bedside, the children divided up her meager possessions, a clock, some pictures, a broken slot machine.

Grandma and her children experienced the full depth and breadth of life. They also enjoyed the richness of life because they experienced the extremes that life had to offer. Grandma also experienced the frailty of life with two of her children dying and four of her sons in harm’s way in World War II. But this relationship with hardship and death also served to embellish the simple joys of family. Her soul understood that life is truly a gift. At the end, Grandma had no regrets. Her heart and soul understood that death was a natural conclusion to life.

This anecdote, my “Grandma dying tutorial,” has been my favorite to tell internal medicine residents and critical care fellows during bedside rounds for the past 30 or so years. This is especially true in the last 10 years. After 20 years of delaying death in my patients, I’ve discovered that maybe my greatest gift as a critical care physician is to facilitate a natural death. After practicing, “Death must be conquered!” for many years, I long for the peace at the bedside seen with my grandmother. This is the message to my doctors in training. This wisdom is the product of years of doing it wrong.

I extracted meaning from my family history that in the beginning was visceral, incompletely understood, felt to be important only at an emotional level. Gradually, I came to recognize these truths buried in that history that are guideposts for each of us. These are the common denominators that give meaning to living and dying that, in our souls, we seek. Our journeys are often wayward and our vision often impaired when we search for those things that make life satisfying. We tend to traverse the highways that are most well-traveled only to find that in the end, we have been betrayed.




[1]Lodge OR. The Recapture of Guam. Washington, DC: U.S. Marine Corps, 1954. 

About the author

Dr Ron Haake has spent the last three decades in intensive care units training new physicians in critical care medicine. He has board certifications in internal medicine, critical care, and neurocritical care. He is a Fellow in the American College of Chest Physicians. view profile

Published on March 22, 2021

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