Dark Angel

Death is but a temporary fading
We shall go on after taking a breath.
-- Meer Taqi Meer


In the medieval morality play of the same name, the title character Everyman is visited by Death who informs him that it is time. Everyman pleads for mercy, protests that he is not ready but to no avail, Death informs him that he must make the journey but tells him that he may take a companion with him. In despair, he casts about for help. Fellowship, representing his friends initially agrees but when he hears of his destination, refuses to go with him. The same with Kindred and Cousin, representing family. He is forsaken in the same way by each of the allegorical characters; Worldly Goods, Knowledge, Beauty and Strength. Only one, Good Deeds agrees to accompany him to the end illustrating the Christian moral of the play: only good deeds accompany a person beyond death.

Terminal illness, death and grief have always been fertile ground for therapy and my recent brush with it was enlightening. Late in the evening as I was getting ready to leave my clinic I saw the blinking phone light indicating a new message. It was a woman who identified herself as a relative of Ms. M who I had treated in the past. Ms. M, an elderly woman in her seventies, was in a local hospital from complications of pneumonia, had developed respiratory failure and was on a ventilator (breathing machine). In her will, she had named me as her ‘health care proxy’, meaning if there were any further complications, her doctors were to contact me and accept my judgment as final including turning off the machine if her condition was felt to be terminal thus allowing her to die. Even though I had always been interested in end of life issues including death and grieving, this was a little unsettling. I called the family back and told them I would try to help in whatever way I could.


Much has been written about death over the centuries. While dealing with terminal illness and death is never easy, in a poor country like Pakistan, there is a more resigned attitude towards it. This is compounded by the lack of access to adequate health care for the majority of the population. During my medical training in Lahore helping people fight off serious or life threatening illnesses in the hospital was a herculean task often ending in frustration and failure due to lack of simple blood tests and medications. By the same token though, nobody lingered on in a debilitated state for too long. Either they recovered and went home or they went on to their ‘heavenly abode’. Partly because of this all of us as young trainee doctors in Lahore developed a sense of medicine in a social context i.e. how social factors such as poverty and lack of education affect a person’s health. I still remember a young girl, perhaps in her twenties, mother to two or three young children who died while I was a trainee in our Tetanus ward. She had contracted Tetanus, an easily preventable disease from having used a dirty rag to clean a minor wound. By the time we saw her in the hospital, she was already in the advanced stages of the illness, paralyzed and having repeated seizures. She eventually died of respiratory failure since we had no working ventilators or breathing machines in our ward.

Ms. M, although she was a life long smoker and had severe respiratory problems from it, had no trouble accessing the best health care since she happened to be an American. Unlike tens of millions of Americans who lack adequate access to health care, she was also elderly and thus covered by the government healthcare program for the elderly and disabled called Medicare. It was spring, ‘flu season was in full swing and she had developed a cold, then pneumonia and now was on a ventilator and unconscious. Somewhere along the way, she had decided after having seen me for a few visits that she liked me so much (or perhaps disliked or distrusted her family enough) that she put me in charge of making life and death decisions for her. Until the phone call, I had no idea she had done this. I remember thinking rather ruefully that this was my reward for being so interested in the subject of death and dying.

Unlike most industrialized countries of the world including Europe, Canada or Japan, the US has never had any semblance of a ‘national health care’ system meaning the government has never assumed responsibility for providing a basic level of healthcare for all citizens. This has always been denounced as too ‘socialistic’ and since profit is the supreme goal of all capitalist enterprise, healthcare too has always been subject to the profit motive. Over time with the efforts of various social and political movements, more health care has been offered to segments of society that cannot purchase it in the open market. This has come to include the elderly, children, those disabled from physical and mental illness etc but there are still vast numbers of people who get by from day to day without basic health coverage, one major illness or accident away from financial ruin and poverty.

In such a system, dying is bad for business. The dead take no medicines, do not get admitted to hospitals and make no money for anyone. Therefore, if it can be helped, people are not allowed to die. This became painfully clear to me in my first year in the US when as a young intern in a large hospital for retired military personnel, I treated patient after patient admitted to the hospital from local nursing homes. Many were in their eighties or nineties, had advanced dementia, could no longer speak, walk, eat, dress themselves or perform any daily activity yet were kept alive by the application of the latest medical knowledge and technology. As trainees, we were expected to treat these elders when they developed an infection, a bed sore from lying on one side for too long or some other medical complication. I still remember trying to draw blood from an old, black man who must have been about ninety and, for all intents and purposes, could do nothing at all except lay in bed in a fetal position. It was 2 in the morning, I was exhausted and after trying to get his blood for the third time while he tried to punch me, the absurdity of what I was trying to do seemed comical. I became increasingly vocal about my views as I progressed in my training to the point that one of my teachers in my last years of training jokingly nicknamed me ‘the executioner’ for my opposition to keeping people alive in this state.

For the moment, though, this was the state Ms. M was in and fate, with her usual macabre sense of humor, had appointed me her guardian angel. The first thing I needed to do was find out what she herself would have wanted. I talked to several family members, all of whom had been estranged from her for years and many who were now consumed with guilt for having been out of touch. After some discussion, we decided that she would probably not want to linger in the state she was in for any longer than she had to. In the meantime we had to decide how aggressively we wanted to treat her as her chances of complete recovery were slim.

A person who is dying can arouse intense feelings in those around them. For the family, there can be regret, guilt, anger and shame for having ‘mistreated’ (in their minds or in reality) the dying person. ‘Survivor’s guilt’ is the self descriptive name given to the condition where the surviving family or close friends suffer for having lived while the loved one died. This can be particularly intense if the death is sudden, unexpected or traumatic such as in an accident or sometimes in wartime. It can be overwhelming if the dead person is a child or if, as happens in my profession, the death is by one’s own hand. A terminal illness in an elderly person usually allows for partial grieving to occur while a person is still alive and thus may mitigate the grief after.

According to some, even though death and its reminders are present all around us, most of us work hard at ignoring them until it forces itself into our awareness because of the death of a loved one or our own brush with it. This is one of the reasons that a parent’s death is so hard, particularly the last surviving one. We are now defenseless against the dark angel of death and must fight it alone.
Fortunately for me, Ms. M eventually recovered from her pneumonia and I was never called upon to ‘pull the plug’ and send her on her way. I have not seen her since she recovered but I hope she and her family found forgiveness and love in her illness and are closer as a result. A brush with death or serious illness can, in some cases, be liberating. Having faced the end, one can now see day to day life as transient and feel free to create our own meaning for it. It can allow for a calm equanimity that is possessed only by those who reflect deeply on life and accept its evanescence.

Some Buddhist teachers call this ‘embryonic compassion’, the seed of true compassion and love for all beings. It forces us to face life in all its beauty, pain and joy rather than forever looking away while we reach for the next item on our ‘to-do’ list. Socrates is reputed to have said ‘the unexamined life is not worth living’. Each and every one of us faces choices, fears, joys, sorrows, hopes and disappointments every moment. It is only when we slow down enough to savor them that we are truly living.



Further Reading: Love's Executioner & Other Tales of Psychotherapy by Irvin D.Yalom