How I Want to Die: Teaching Ethics and Death in Medical School

It was a simple assignment. Fill out an advanced directive or Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form and the Five Wishes form, and reflect on the experience of confronting death from a medical perspective. Easy. And yet, after four years of writing classes and a degree in English language and literature, this assignment was the most difficult essay I have ever had to write.

paperwork reading "advanced care directive"I can count six times when I sat down at my desk with those forms. I would settle in with a warm cup of tea and a pen, clicking it in, out, in, out, and stare at the MOLST form. I’d begin to write “Horiates, Marina J” in that first box, and I couldn’t do it. I would read the form over and over, would flip to the next page and begin reading about the Five Wishes, and every time I would go to write my name, I would cry.

It felt pathetic, to just sit there and be completely unable to finish one simple assignment because I couldn’t stop crying over these forms. I even tried taking the forms to a Starbucks, in the hopes that sitting in a public place would prevent me from just losing it. That, of course, didn’t work at all. I pushed them off longer and longer, causing the text from the forms to float into my mind as I was going to sleep: What do you want your loved ones to know, the person I choose as my health care agent is, I wish to be kept clean and warm … I found myself calling my brothers, my parents, my grandmother and my close friends more frequently than I had all semester, repeatedly telling them how much I loved them and missed them, but I couldn’t bring myself to talk about this assignment with them.

On the MOLST form, death is a matter of one checkmark. One. “Attempt CPR” or “No CPR, allow death to occur naturally.” In some ways, these forms were the first time I really sat down and thought about death from a physician’s perspective — this cold, administrative question of “arrest.”

The day before the assignment was due, I completed my medical student CPR training on a rainy afternoon in the Sim Center. I felt in my hands the action of the “life-sustaining treatment” these forms refer to — 30 chest compressions, two rescue breaths, repeat. I felt that strange twinge in my gut when the instructors told us we could stop resuscitating our mannequins; it was time to move on to the next exercise. That helpless feeling when I had to sit back and let my red, sore hands fall to my side and stop pumping the “blood” through this patient’s plastic heart because some authority told me I needed to stop life-sustaining treatment now. “No CPR, allow death to occur naturally.”

For me, the most difficult part of these forms was imagining everyone else around me. The physicians who would decide whether or not they believe life-sustaining treatment would help — whose red, sore hands would eventually fall away from my chest when CPR was no longer going to save my life. My dad, what I wanted him to think about and try to decide for me as my health care agent, should that become necessary. What I wanted to him to know, imagining his face and his eyes, trying to read these forms that are suddenly all that remains of my voice. My family, imagining them having to find a flight from Dallas, arriving here, seeing me and realizing how deeply I didn’t want my parents to have to outlive me, to watch this when they’ve already been through so much. My brothers, my grandmother, my friends, what I wanted to be able to tell them.

And finally, the strangest, most difficult moment for me. On the morning of our last ethics class, I found myself sitting at my desk again with my pen hovering over the final question in the forms. In neat little black letters, the form asked whether I wanted to limit in any way the standard definition of life-sustaining treatment for myself. I found myself writing one sentence: “I do not wish to limit the above definition of life support treatment — keep me alive.” And I sat there for a moment, laughed a little and shook my head. My eyes filled with tears again, and I thought of my parents, my brothers, my friends. I thought of how impossible it would feel to let them go under any circumstances and how much harder it would be to do so if I could see in their own handwriting the phrase “keep me alive” when it was so clear that no one has the power to do that.

At 22 years old, I sat there and realized how difficult it was for me to grasp the thought of letting go, to recognize that I was really going to die at some point. And so I clicked my pen once more, in, out, in, out, and slowly scribbled through those final three words, tucked the forms away and, for the first time in my life, let go.