by John Loofbourow, MD

About 2500 years ago Charon was the mythological boatman who helped the disembodied Greek soul across the river Styx. He insisted on a small fee for his services, so that Greeks were buried with a coin in their mouths, lest the soul languish forever on the banks of that dark river. The astoundingly successful technologic accomplishments of medicine today have devalued that coin to the point of worthlessness, and channeled that river Styx through the Extended Care Facility. There, in an often foul and fluorescent air, many Americans hopelessly wait. Ironically, our society provides this costly and cruel "care" with good intentions.

In Woodland I once cared for a decerebrate teenage woman who had survived but did not awaken from a head injury. Her father was with her almost constantly during the first few months searching for a sign of cognition, pouring into his child every shred of love and strength he could. Today, twelve long years later, he still visits often, to hold the hand, touch the face, and speak words of encouragement to the memory of his lovely daughter. For several years her young body retained its form and promise, despite a constant deviated gaze, teeth grinding and frequent seizures. But in time she underwent a heart-rending metamorphosis with muscle wasting, and skin and tissue changes from medication and chronic invalidism. Her bodily needs were addressed by various catheters and diapers. She is now a "no code," but her frequent infections and pressure sores are treated. The "Old man's friend," pneumonia, is not allowed to intervene nor to assume the duties of Charon the boatman. She waits. Her father waits. Now, presumably, the State, its Care Managers, treasurers, and taxpayers wait also.

My dear friend and colleague had developed a persistent cough and ordered a chest x-ray on himself one night while on duty. Both lung fields were riddled with multifocal lung cancer. Following pathologic confirmation and a decision to attempt chemotherapy, he and his wife threw an all-day swim party, attended only by his families: those of us he lived with for eight or ten hours daily and those in his genetic family with whom he had shared the rest of his life. It was a celebration of all he was, and all that we all are; characteristically, and a bit defiantly, we planned for another party a year later. He deteriorated rapidly, yet focused clearly on two things: 1) reaching out to his family and 2) avoiding hospitalization. Both his families assisted him to reach back into his own life, and to reach out to his own death. As a practical matter we had shifts, so that a member of each family was always there during his last weeks. This sharing of responsibility among those who lived life with him and those who worked with him was a poignant and transcendent experience. Our friend and colleague was never hospitalized during his remaining four months.

To paraphrase Don Juan, Carlos Castaneda's Yaqui Indian philosopher, who usually speaks in metaphorical and mystical terms: death is a black crow that is always with you; if you turn your head quickly you can sometimes catch sight of it flying away; in any life crisis, your own death is your best counselor. Nonetheless, Don Juan is a Warrior and in old age he "fights like hell," knowing that in the end he will lose. Yet we are not allYaqui warriors. As physicians we see people who want release from life. They find support from Biblical sources as Ecclesiastes (4:2-3 "there is a time for all things under heaven: a time for birth, a time for death, ...") to the lamentations of Job, and the dire predictions of Revelations (9:6 "... they will seek death, and not find it:". Maybe the Revelations author refers to a nursing home?). They point to Native American cultures like the Aleuts, whose elderly are allowed to walk out into the cold when they are ready to die. They see in Eastern cultures an understanding and a tolerance or respect for the continuing cycle of inter-related life and death that is comforting.

Beyond patient directives that the medical community limit interference with dying, they would like us to accept their decision to expedite the end of their own life. What is free will, after all, if such an option is denied them? They would like to be counseled and assisted in considering or acting upon their will to die, in a way and at a time of their choosing.

So I wonder if the time is here when a subspecialty of Geriatrics (gerontology) will become practicable, legally, ethically, and culturally. It might be called Charontology. Consistent with modern circumstance, the practice of charontology will require a team approach, and wherever possible, much greater patient/family participation. Charon's fee might be more than a coin or two in the client's mouth, although a low-cost fare across the Styx should be included in any good prepaid care package.