By Doctor Kamal S. Kalsi, MD, Major, United States Army. Death is not the enemy… I am many things, but on a good day, I’m an ER doc. Last night I took care of a patient that had been bed bound in a nursing facility for at least the last 7 years. She had bed sores the size of my hand. But that isn’t important right now because they’ve rushed her in for her cardiac arrest. I look at the wasted remains of what probably was once a beautiful body. “She’s a full code doc,” I’m told with a sense of sympathetic urgency. Tubes are everywhere… there’s one to feed her, one to help her breathe… I throw one in so that we can give her the necessary medications needed for resuscitation. I don’t feel a pulse. We start compression’s, feel the crackle of breaking ribs and dark blood begins oozing from her mouth. She has a gastrointestinal bleed. We rush to pour blood into her. She must be 100 years old. My mind flashes back to all the soldiers we took care of on the front lines in Helmand. Blood is everywhere. That smell and feel of blood is something you never forget. “I got a pulse” I tell everyone after several rounds of epinephrine, atropine and bicarbonate. In my heart I know this body will never recover. She will go to the ICU and will probably die there. The family still wants “everything” done. We dutifully torture the life out of these bodies. Cold. Lifeless. Inhumane. Death is not the enemy… I am. These types of sad and futile exercises have become a common fixture in emergency departments nationwide. A large part of what makes this issue so prevalent is heart disease. Cardiovascular disease remains the number one cause of death in the U.S. today. Annually, this translates to more than 600,000 deaths. Based on the Resuscitation Outcomes Consortium data from a report published by the American Heart Association in 2015, survival to hospital discharge after EMS-treated non-traumatic cardiac arrest with any first recorded rhythm was 7.3%. Essentially, if you have a cardiac arrest, the odds of you walking away with a good neurological outcome from that event are not in your favor. Most of my doctor and nurse friends openly discuss that they do not wish to be resuscitated when their time comes. Why is that? There is a natural tendency for a healer to want to “fix” the human body when things aren’t working right. But death is a natural process, and desperate attempts to prolong life often simply end up prolonging the suffering. What follows from this is that a large percentage of our healthcare dollars are spent in the last few years of life. We live well in the U.S., but we haven’t learned how to die well. Perhaps it’s because we don’t respect death. Death is an uncomfortable topic. How many of you have been to your doctor’s office and had a frank discussion about your death? Overall, Do Not Resuscitate (DNR) orders are more common now than they were just a few years ago. However, my experience has been that these difficult conversations are happening much less frequently in communities that are economically or psychosocially challenged. In immigrant communities like mine, it is exceptionally rare to see a patient come in with a DNR. Our understanding of death has evolved. Clinically, I can declare a patient dead when they have no signs of life (i.e. – no reflexes, no cardiac activity, no respirations). But the numerous complex systems of the body sometimes don’t talk to each other when they’re closing the shop. It is possible to have a brain dead person who is breathing and has a heartbeat. Most states now recognize that a person is truly dead when they are brain dead. A variety of different scanning methods that look at cerebral blood flow or brain activity can be used to determine brain death. At that point, if a patient is declared brain dead by the medical team, they can and should withdraw all care to allow a natural progression to death for all the other organs in the body. ICU care costs can run well over $10,000 each day. Insurance companies may no longer cover the costs of care once the patient has been declared brain dead. I have seen families become destitute while bearing the burden of these costs, all the while insisting that everything should be done. When it is apparent that the patient will not recover, it our duty as physicians to compassionately help the family understand that any further efforts are futile. So today I implore you to have the conversation. Talk to your family and your doctor about palliative care, hospice and DNRs while you still have the ability to make decisions for yourself. As a practicing Sikh, I see this life as simply a journey of learning, love and service. I believe that death is not an end, but simply serves as a transition point for the soul. Regardless of what you believe, a peaceful transition without extraordinary measures is a practical and compassionate approach to the end of life. We may still not understand death or what lies beyond it, but we must learn to respect it. -Dr. KS Kalsi, MD, Major, United States Army Reserve. Dr. Kalsi was born in India and arrived in America when he was two years old. Within his family, Dr. Kalsi is fourth generation military service. Dr.Kalsi’s Great-Grandfather served in the British Army, his Grandfather and Father served in the Indian Air Force. Dr. Kalsi is an Operation Enduring Freedom Veteran and currently resides with his wife in New Jersey, USA, where he serves as the EMS Director for the Saint Clare’s Health System.