The Source of All Things

by Reinhard Friedl

  * * *

  The ringing of the telephone tore me away from my thoughts. My mother was calling. My father had not been well for some time. My parents had been married for over fifty years. They were, so to speak, at the end of the path that Yücksel and Huyen may just have started together.

  “Can you come home soon?” my mother asked me. “Papa is not feeling well. The doctor says his heart is getting weaker and weaker.”

  DANSE MACABRE

  Some days later I was on the train home. Maybe this would be my last visit to see my father. A few years ago, he had had a new heart valve implanted by a surgeon who was a friend of mine. Dad and I had talked about his life, and about death, before and after this procedure. He had helped create me many years ago; perhaps soon I would hear his last breath. You might wonder why I did not operate on my father myself. It’s because emotions are unpredictable. Even for surgeons. The fear and pain would have been too great and might have diminished my matter-of-fact way of functioning, which would have been so vital.

  * * *

  Dying is a spoke in the wheel of life. Humans die permanently and are reborn every second. Fifty billion cells perish in our body every day and are replaced by fresh ones. Statistically speaking, every single cell is replaced within a year, as well as 98 percent of atoms and molecules.1 However, we do not perceive this programmed cell death; we remain the same, after all. Or so it seems. But our soul or self changes throughout the course of our lives, due to perception and knowledge.

  In various spiritual traditions, the death of the ego—one could also say its transformation—is viewed as a high level of knowledge. Not all people reach this level of consciousness, and mostly the ego dies last. This is recognizable, every now and then, from the gigantic tombs with which some attempt to defy mortality. In paintings from the Middle Ages, death is depicted as a creepy skeleton; it dances through the crowds and takes whomever it wants. The death dance of modern medicine is more varied: clinical death, natural death, unnatural death, heart death, brain death, and cell death are its main performers. Not all are in the cast for good. And one variety gives empirical science a hard time indeed: the phenomenon of near-death.

  When is death real?

  According to an accepted doctrine, a patient whose heart has stopped, whose brain is not supplied with blood, and who is not breathing does not have any consciousness. Not all patients abide by this.

  In a fascinating study, the experiences of 344 patients with cardiac arrests were examined. If the electromagnetic waves of the heart ECG flatline, it usually doesn’t take more than ten seconds for a person to lose consciousness—and in the brain, too, the EEG can no longer detect electromagnetic currents. As the term “loss of consciousness” expresses, one would then expect that everything becomes dark for this person. However, for 18 percent everything became light, and they embarked on a journey: they experienced how they left their bodies—combined with a very pleasant feeling and the knowledge that now they were dead. Some approached a light through a tunnel, saw colors and celestial landscapes, met dead relatives. Others saw their whole life like a film or found themselves at a kind of frontier. None of them passed the frontier irrevocably: all were successfully revived. Therefore they had not died but had had a near-death experience. On our side of this frontier, relatives, paramedics, nurses, and doctors were fighting for the patient’s life. Dutch cardiologist Pim van Lommel was interested in what patients had experienced at this frontier, and recounts this in renowned scientific journals and his book Consciousness Beyond Life.2 Based on current estimations, 4 to 5 percent of the Western population have been granted a glance into another world. Ultra-modern high-tech heart medicine seems to open a window for us onto otherworldly dimensions. It becomes ever more successful at bringing moribund, critically ill patients back to earthly life when they are at the threshold. At the threshold of what? Of the hereafter, of another world, of new dimensions? Some scientists believe the “apparitions” are merely the final convulsions of the dying brain. But what happens if a brain specialist experiences something like this themselves? It happened to American professor of neurosurgery Eben Alexander, who had been in a deep coma with severe meningitis. In his book Proof of Heaven: A Neurosurgeon’s Journey into the Afterlife, he describes his near-death experience, which lasted several days.3 Sometimes this state occurs after an accident with severe loss of blood or a serious head injury. Even children who have nearly drowned speak of it, and occasionally a dying person may experience a visionary glance into the afterworld from their death bed.

  * * *

  For many people, dying is a phase of life, a transitional stage in which the spirit detaches itself from the body. Our bodies, bones, and organs are made from the elements of the earth and return there. After the process of dying we are dead. But for many the spirit, the soul, or pure consciousness lives on as a continuum without beginning or end. Scientists such as Eben Alexander and Pim van Lommel also arrive at this conclusion. Yet it is not at all new. It can be found in the age-old teachings of Christianity, Islam, and many other spiritual traditions. There are different ideas as to which “visa” the spirit will be given and where the journey onward will lead.4 However, free entry is guaranteed for every human being, independent of their gender, race, or origin and disregarding whether they are poor or rich, good or evil. But what and where are we once the heart is silent?

  * * *

  People’s near-death experiences can shed some light on this. Their reports betray astonishing similarities across nations and cultures. In the aforementioned study, they perceived the “celestial” journey as something very beautiful. They were interviewed again after two and eight years and compared with people who had not had near-death experiences. Although the experience had in most cases not lasted more than a few minutes, the survivors remembered it very well even years later. It had profoundly influenced their further lives. They were better able, afterward, to show their emotions. Love, compassion, and spirituality had become more important for them. People who had a near-death experience spoke of their increased belief in a life after death, and the majority had lost their fear of death. They had experienced that their conscious being did not cease when their brain and heart stood still.5

  A matter of life and death

  Some patients who are revived after a cardiac arrest have to be operated on immediately; this is extremely risky, as after an infarction sections of the heart muscle aren’t supplied with blood and start to die. The heart has no reserves left and no power to supply itself and the other organs with sufficient blood. The patients suffer from oxygen shortage, their cells die en masse, so the whole person does too. This stage is called cardiogenic shock. The deadly downward spiral has to be stopped as fast as possible if there is to be any chance of survival.

  In an induced coma and with heart medication at high doses, the patient is quickly wheeled into the operating room. The heart disease in question here is usually far advanced. Heart surgeons try to restrict themselves to the bare essentials in such cases. The longer the cardioplegia lasts during the operation and the longer the connection to the heart-lung machine is required, the graver the repercussions will be for a body already down for the count. Sometimes bypasses and a new heart valve have to be implanted. Or a new aorta straight away, as I described in the chapter “Heart on the Table.”

  * * *

  Statistically speaking, the mortality rate for heart operations is very low. On the operating table, only extremely severe cases end in death. For example, an acute cardiac arrest involving a tearing of the heart wall, or sometimes an accident victim with grave injuries to the heart and lungs whose vessels have ruptured. I remember a young woman who was crushed in her car during a horrific accident. She reached the ER of the clinic alive, and my colleagues from emergency surgery attempted to stem the life-threatening bleeding via an operation. But she did not improve. What had not been clear at first glance was that the heart and the large blood vessels near the lungs were a
lso injured. I was called into the operating room. Specialists from different fields were examining a heart which was only twitching weakly. The shock room resembled a battlefield. Long metal vessel clamps protruded from the open chest. The connections of heart and lung had been partially severed, and the patient’s pupils were wide and fixed—a sign that her brain, too, was no longer responding. For this patient—and for quite a few others—there was nothing I could do.

  * * *

  When a person dies during a heart operation, a loud silence sets in, in a manner of speaking. This silence does not really seem quiet, even though we switch off the devices and the humming and beeping and the clatter of stainless steel ceases. Rather, the sounds from our fight for the patient’s life seem to hang in the air still. The team will remain standing at the table for a while. According to their individual disposition, they mourn, feel exhausted, disappointed, empty, or furious. We have given our best, but this patient’s fate had something else in mind.

  * * *

  To see a heart flutter hurts me. But to see a heart die really gets to me—and is, at the same time, a spiritual experience of finality. Some hearts announce their death through fluttering, others beat to the last moment. The heart will become slower and slower, weaker and weaker. But it is still beating. And then it seems to me that the weak beating becomes more peaceful. Sometimes it gives the impression of giving up or agreeing to go. We who stand around the open heart in a circle, we follow and let it go. At this point we will have done everything humanly possible to save the patient; we will have fought and tried again and again to wean the heart from the heart-lung machine, three or four times. But without that support it took a turn for the worse, became too weak to support the body, too weak to look after itself. And so we disconnect the body from the heart-lung machine, knowing it will die. Such a death announces itself. The heart beats and pauses and beats again, and then the pause before the next beat becomes longer. Its beats are weaker, and the pause becomes longer still. And then it will beat one more time and never again.

  * * *

  If there is even a small chance for the heart to recover, we connect the patient to a permanent mini heart-lung machine; this is called extracorporeal membrane oxygenation (ECMO). It is an extremely invasive measure with many possible complications, as the patient is attached to a machine for days or weeks and bleeding, infections, and strokes may occur. The use of ECMO is discussed by the whole medical team, as it has far-reaching consequences from both an ethical and an intensive care perspective, and many questions have to be answered. Does it make sense to keep prolonging the patient’s life? Can we really improve their chances of survival? Such patients often receive massive transfusions, they are connected to dialysis devices, require artificial respiration, and are kept alive with medication of the highest possible doses.

  Above it all towers the question: How will the brain react? Has there been a resuscitation, and was it effective enough for brain damage not to be likely, or will the patient, should they survive, be severely disabled and become dependent on care? Would they have wanted that? If, after sober consideration, we think a patient has a chance, however small, we will take it. Even if we see the possibility that the patient may die after a few hours or days in intensive care. Heart surgeons are advocates of life; it is their task to save lives even when the situation appears hopeless. They are always the last resort. After us there is no other medical possibility. In competent care, patients may survive such extreme interventions. And then it will all have been worth it!

  * * *

  The decision to let a patient die is not made by the surgeon alone, but if at all possible together with experienced colleagues whom I ask to join the discussion. Perhaps they have another idea, a suggestion? If I operate at night and no one is in the clinic, I seek the advice of my assistants and anesthetists; personally, I do not think that is a bad thing, since they have followed the course of events from the beginning. They have a connection with the patient’s heart, while someone who is called in and informed about the case does not know its history, or else only its medical aspects—and that is not the whole truth. An open heart involves so much more.

  * * *

  It may sound strange, but I feel closer to the dying heart than to the patient. I have been in touch with the heart. I have got to know it. I recall its face much more clearly than the face of the person, with whom I may not even have spoken before the operation, or only briefly, as it was an emergency. I do not know them. But I have come close to their heart, have advanced into its deepest cavities. And it is their heart which I say goodbye to—a defeated farewell, because I have lost the fight against death. Usually I suture the chest myself in such a case, rather than leaving it to my assistant. It is a final service to the patient. There is a peculiar atmosphere in the operating room. It may be quiet, or someone has to tell a joke, or everyone becomes noticeably busy. We have nothing left with which to oppose death, we have to bear it, each in our own way.

  * * *

  The dead patient’s age, of course, is a factor as well. A young person’s death, or a child’s, is hard to cope with. I remember a family man in his mid-thirties who was in limbo between life and death for weeks in the intensive care department. His plight touched us all, especially because his three small children came to visit with their mother on Sundays. It was a little as if they were reminding the team why it was worth fighting for this patient. On a mild August night, we knew that he would not see the next day, and called in his wife. On the monitor she could see her husband’s heart becoming slower. And even though she was prepared for this, she was not able to just let him go. She beat her fists on his chest and screamed: “You must not die! You must not leave me behind!”

  That was hard to bear. I looked through the window, which was slightly open, hoping the other patients would not hear the woman’s screams. On the windowsill was a bag of dialysis fluid, weighing about three kilograms. The dying man’s heart became slower and slower. “You must not go! You must not! Stay with me!”

  After the last heart tone there was silence, and then a gust of wind threw the window open, knocking the bag into the room, where it exploded on the floor with a bang and caused a flood. I exchanged glances with a nurse. It seemed like we were thinking the same thing.

  Dead people with beating hearts

  Nothing lasts forever, and a heartbeat only lasts a moment. Many moments add up to form your life. Most people believe they are dead when their heart stops beating. Today we know this is not quite true. Maybe they are only clinically dead. That is the case when a cardiac arrest is not final and resuscitation is carried out successfully. If that doesn’t happen, all organs begin to die within five to ten minutes.

  * * *

  The brain can also expire of its own accord—in the course of severe illnesses or accidents: for example, through bleeding or meningitis. The heart is still beating, and the other organs are alive. Such a patient can no longer breathe by themselves and has to be given artificial respiration.6 Doctors call this brain death. It is the latest performer in modern medicine’s dance of death. It was first defined in 1968 as the final, irreversible end of all the brain’s activities. Doctors may then testify to the death of the whole person and remove the organs of the beating heart cadaver, if he or she has previously agreed to this. However, it is also possible for a brain-dead person to continue to live for twenty years, connected to an artificial respiration device.7

  * * *

  The case of thirteen-year-old Jahi McMath caused quite a stir some years ago. There were complications after a tonsil operation, her heart stopped, and she had to be resuscitated for two and a half hours. Her heart stabilized, but her brain had lost any detectable function. She was pronounced brain-dead, and it was recommended to her family that they allow her organs to be removed. Her skin was warm and rosy, her face relaxed. Heart, lungs, kidneys, liver, pancreas, and intestines were to be taken. After that, her artificial respiration would be stopped. But her
family resisted. As long as her heart was beating, they saw Jahi as alive. There followed years of a lawsuit about the question of whether she was dead or merely regarded as dead. Four years after the operation, Jahi died from internal bleeding.8

  * * *

  Brain death is a definition, and when this definition is applied to a person, they are issued a death certificate. They are pronounced dead, even when (with the exception of the brain) all organs are alive and their heart is beating. In such cases, organs may be removed for transplantation. Behind this is the categorical will of visionary doctors to save human lives. Transplant surgeons take organs and tissue of the brain-dead person and implant them into other people. That is truly magnificent and has my full support. What is problematic, though, from my perspective, is the claim that the organ donors with a beating heart are dead. Not long ago a woman in Germany gave birth to a healthy child, after she had been pronounced brain-dead two days earlier due to meningitis.9 Her heart was still beating, her brain no longer working. In my opinion, the doctors acted correctly in letting the child be born and the mother die afterward. But modern medicine poses new questions: When is dead really dead? Can the dead give birth? And how do you think about organ donation yourself—will you sign up as an organ donor or not? Would you bury a brain-dead relative who is given artificial respiration, while their heart is still beating? Or burn their “corpse”? This last question is brutal and macabre, but demonstrates how much confusion the diagnosis of brain death can cause.10 No one wants to be pronounced dead while they are still alive.