The Last Illness

By J.C

Thou shalt not kill; but needst not

strive

Officiously to keep alive.

--Arthur Hugh dough

Since the Victorian poet wrote those lines a century ago, doctors have become highly skilled in maintaining a spark of life in even the most aged and debilitated of patients. Harry Truman's last days underscored that ability--and raised again the question of whether such heroic medical efforts are really merciful.

The stubbornness of Truman's fight for survival at age 88 reflected to no small degree his strong constitution and will. As his personal physician, Dr. Wallace Graham, put it after his patient had been hospitalized for two weeks: "President Truman is showing remarkable strength and tenacious physiological reactions, which are a reflection of his attitudes toward life." But a second factor was also important. For so illustrious a patient, Kansas City's Research Hospital and Medical Center was certain to try every conceivable medical stratagem and device in the hope of pulling him through.

Truman's was not an extreme example of prolonging life artificially after no rational hope for recovery remained--although the vast majority of patients admitted to many ordinary American hospitals at Truman's age and in his condition would have been dead within a few days. The measures taken to keep the ex-President alive for 22 days were numerous and elaborate, as spelled out in no fewer than 80 medical bulletins.

Ultracritical. As Truman's physician since his White House days, Surgeon Graham was forewarned of how this last illness might manifest itself. When he was under exceptional stress as President, Truman had developed noisy breathing (technically, "rales") which, Graham recalls, he seemed able to control by sheer will power. Over the years the rales recurred occasionally. About two years ago, Truman pointed to his head and told Graham: "I feel as though I have a little hot wire up here." When he had that feeling, the ex-President lost some of his famed alertness. Also, he said: "My eyeballs are changing around." This was an early indication of cerebral arteriosclerosis, common at his age.

In the initial phase of Truman's last illness, which began a month or more before he was admitted to hospital, treatment was routine: bed rest, to ease the burden on his lungs, for the rales were again noticeable. There was intermittent impairment of mental function. Graham prescribed antibiotics to reduce an infection in the lungs. On

Dec. 4, Truman was out of bed, ate well, seemed much better, and then, in his doctor's words, "just hit bottom." Graham had him admitted to Research Hospital.* Truman was conscious, his condition was rated "fair," and he was expected to recover. Only 26 hours after admission, his heart began racing at 140 beats per minute, his blood pressure dropped to 80 over 60 (120 over 80 is normal), and respiration was failing. To pull him through this "ultracritical" period, doctors placed an oxygen mask over his face, and gave antibiotics by intramuscular injection to help combat the congestion in the lungs.

After that, it was one strong measure after another: antibiotics by intravenous injection; "pressor" drugs to normalize the blood pressure; carbon dioxide, by mask, to help balance his blood chemistry. A thin tube was threaded through the patient's nose and throat into his stomach for feeding with a liquid preparation containing amino acids, protein and vitamins. Then, eight days after his admission, Truman's kidney function began to fail, evidently from inadequate blood supply. The kidneys could not extract nitrogenous and other wastes from the blood. To reduce uremic poisoning and maintain some nutrition, the doctors tried feeding Truman a mixture of amino acids (flown in especially from California). This helped some, but not enough, for all of his metabolic processes were failing. Internist Wilson Miller and Kidney Specialist Robert Muth considered, but rejected, use of the artificial kidney; they decided that it was too late for this to do much good, because of cerebral and coronary artery deterioration.

Though he recovered sufficient consciousness a couple of times to say he felt "all right," and to indicate his displeasure with the oxygen mask and the intravenous tube hookups, nothing worked. Gradually, the complex, interdependent body systems essentail to life --notably heart, lungs and kidneys -- all failed, despite repeated infusions to boost blood pressure. Truman was in a coma for days, and died the morning after Christmas, 22 days after admission. Though it was natural for the medical team to fight hard against death, there was still a temptation for laymen -- and even some doctors -- to wonder why he should not have been allowed to go in peace. It is a question frequently debated by theologians, lawyers and doctors, but the issue is not subject to consensus solution. Are a few days or weeks of half life worth anything to the patient? Do the patient's interests, his family's hopes and the professional reflexes of doctors sometimes conflict? In the gut language of hospital corridors, who decides to pull the plug and when?

For Truman's case, one of his doctors answered forthrightly: "I could not have shut off these life-support measures for anything in the world. It's just something you don't do. I don't think you can say Mr. Truman suffered at any time." There would be less room for disputation if that were true of all patients, but it is not.

Shaw's Advice. Dr. William Poe of Duke University, an outspoken opponent of keeping the incurable alive by extraordinary means, commented last week: "Had I been in President Truman's place and had my wits about me, I would have said: 'Please spare me the anguish. Please don't pour life into me, don't treat me like a machine.' " But, Poe concedes, "it is likely there would be natural pressures from a wife and a highly educated daughter to keep the patient alive despite the inevitable. And in this case there is another pressure: 'We can't let a former President die without a helluva fight.' More and more people are saying, 'Desist, let me go in ease, just make me comfortable.' But physicians are not trained to accept death as an alternative."

The fact is that doctors are graduated from medical school with a built-in dilemma. Their Hippocratic oath requires them not only to preserve life but also to relieve suffering. With the span of life being lengthened and with medical wizardry increasing its skills, there will be more and more cases in which one Hippocratic obligation is in direct conflict with the other. Whatever value may be put on George Bernard Shaw's opinion of doctors, he had sound advice for patients: "Do not outlive yourself."

* The rate for his sixth floor room was $59.50 a day, to be paid partly by Medicare, in which Truman held card No. 1, and partly by private insurance.

This file is automatically generated by a robot program, so reader's discretion is required.