6.12.1913  -  12.12.2002

Books of N.M.Amosov

Diary. November, 10

Last week, the November holiday passed. I had to work. Ostap died on the sixth. For eight days he lay apathetic, frightful in his leanness, with half-opened eyes. His look did not express anything, but his eyes were clear. He was conscious, and it was possible to make out his answers to questions if you were persistent.

"Ostap, do you want something to drink? To drink?"

A weak nod.

"And to eat? Do you want to eat?"

Slight surprise in his look. A hardly noticeable shake of the head. It is easy to interpret: "How can you ask such ridiculous thing?"

No wishes at all.

He could not pronounce words — a tracheostomic opening in the neck — the air flowed, bypassing the vocal cords. But he apparently would say nothing. No wishes. He died away slowly. I wanted so much to breathe in life into him. A good chap.

He was in a private room with a doctor-on-duty round the clock. Natasha stayed long hours with him. She put all her soul into him. Doctors used to joke: "She would take him home for holidays."

The main complications were pneumonia and respiratory deficiency.

He was particularly frightful during my rounds on the morning of the fifth: black bristle on the cheeks. His mouth was open. He was too weak to keep it closed...

"He's fading fast..."

Such a term has appeared among intensive care doctors. "Fading fast." It is a fairly recent coinage, and I cannot get accustomed to its clandestine meaning.

On the morning of the seventh, when the band from the parade which was gathering under our windows began to play, they called me:

"Ostap has died."

I did not have the feeling of an irrevocable loss which hits you when a patient who should live dies after an operation which made his heart healthy. An unhappy lonely man who had "exhausted all his resources" had died. The last, desperate attempt was abortive. That was all. He went into an operation with hope and left indifferent.

We must talk about it, and about such death in particular.

In my childhood and adolescence, I feared dying. Life was not easy but extremely attractive. "To disappear" and "not to be" when there are so many interesting things around you and when you think that everything is made for you is not an easy idea to grapple with.

During the war everything changed unnoticeably. Although I did not go to war, we were bombed many times and there were victims. I did not experience fear of death. And I am not saying this to show off. So many people died around me; was I better than they? I did not hide in a slit trench, did not go to bomb shelters, since there were always people around me who were unable to hide — the wounded, the nurses... Apparently, the profession of wartime surgeon had its effect on me: other people's lives were so often dependent on me that I did not lose my presence of mind in the face of death.

My attitude towards death has not changed since the war. There has been no bombardment, but the number of deaths has not diminished. Even worse: I cannot write any of it off to the war; very often I have been the cause of death: I could not prevent it, or I may have even made a mistake.

As time passed, particularly after I reached sixty, the purport of remote objectives began to diminish, since there was no time left for major achievements. It was replaced by the meaning of short-term objectives — activity for activity's sake. Regularly to find out something new by reading books. To perform operations, to nurse patients. To invent something about trifles. To meditate over "the eternal questions" without hope of making results provable and reporting them to others. (To make them happy.) Some biological needs have also changed...

All this taken together gradually diminishes the value of life. I no more view "not to be" as something dreadful. No doubt I am curious about the future, but I know that nothing in particular will take place any time soon.

There is only one weak point left: the process of dying.

Writers of all times have racked their brains trying to imagine how it will happen, what thoughts and feelings they would experience during that process... Each described his own attitude towards death. His own visualizations: recollection of happy moments, struggle; screams of "I don't want to die." Or some "fading" to the accompaniment of quiet sunsets and sunrises. Talented writers knew how to watch and reincarnate. Renowned Soviet novelist Valentin Rasputin is one of them.

I also sense that at that very moment, I will face fear of death and will have a terrifying desire to cling to life. A kind of a storm of feelings like those we experience at a moment of danger or stress. (For instance, during operations.) Maybe my calmness is only a fiction, since I know that there is no immediate threat.

After the war, I began to look for information on people's last minutes or even hours when death was caused by diseases. After the war, I did not meet anyone whose life was mortally threatened daily, for all my associates were young and healthy. I did not have a selfish interest in it — the probability of such a situation, as in adventure films, is minor for me. Not making any allowances for age, even.

But first, a small personal experience.

Four years ago I had influenza, something I catch rather rarely. But it seems that I am capable of being patient and not troubling my family. However, this time, my temperature reached almost 40°C. I had a terrible headache, and all my muscles ached. Lida claims I lost consciousness several times. I think she is exaggerating. They summoned a "first aid" team and I was given injections. The pain subsided.

I did not think of death, but remembered the following: the feeling of complete indifference to everything that surrounded me — the present, the past, the future, my family, and profession — whatever the case may be. I did not have any feelings at all. But I was conscious. I retained the ability not only to observe myself and the feelings related to my own physiology and the disease, but also over my feelings in general and my attitude to my surroundings. I remember very well my thought that if I were to die, I was ready. I put up no resistance at all, since I had no wishes, only a kind of bliss. My thinking was passive and superficial. I simply stayed in bed looking around, short lived associations flickered in my mind and rapidly disappeared. Several hours later, my temperature went down, and I analyzed the condition that I had just experienced. That is why I remembered it.

I had lived through something like this only once in my life. But it gave me food for thought: Was it an exception or a rule? I began to display an interest in the dying — another aspect of observation, apart from medical and compassionate.

Not so long ago, I was listening to a dull report, sitting close to an academican, whom I won't name. I knew he had been operated on. They had found nothing dreadful, but a few days later, he had a bad internal hemorrhage. They barely managed to save him, my friends told me. I thought he had been on the edge; maybe he had later analyzed his thoughts. I asked him about his experience, but it was not indicative. He had had the same experience in the past, and it was similar to mine. He was also in critical condition — on death's door.

"And I remember the last thought that came to me before I lost consciousness: This is the end. And it is not dreadful."

I was astounded by the preciseness of this statement.

Now about my talks with the patients who were brought back to life after clinical death or who were very close to it. I cannot say that I carried out an in-depth study, but I asked a psychologist and my intensive care physicians to make a serious study of this.

They tell the following of the last moments before someone "passed away":

"Indifference. You're all fussing around me, and I look at you and wonder: What's all this fuss about? What is it all to me?"

Everybody notes the dulling of feelings. Almost nobody felt fear. At that point, they seldom think of death; they begin to fear it as soon as they feel better. Sometimes such states develop into psychoses accompanied by hallucinations and delirium of persecution: "It seemed to me that you were poisoning me with drugs." But such psychotic states frequently occur without clinical death and resuscitation.

Their stories are confirmed by observations. We do not see emotional torments on the faces of the dying, although the majority of them are conscious until the last moment. This is a specific feature of cardiac patients.

Rather sad developments.

"To sum it up. There is no reason to fear the final moments of life. Nature takes care of us: feelings die away before the onset of death. It is not dreadful to die."

Therefore, when such a patient as the late Ostap insists on a possibly fatal operation, I can understand him. To live with decompensation and edema, to count each movement and swallow of water, having lost all hope that drugs can help, and to live this way for months and years is tormenting. If there are no other interests, if you are alone or are a burden on your family, then any chances for a healthy life are good, be they only slight.

I can very well imagine how some sensitive individuals will be filled with indignation:

"How could he say such dreadful things!"

And, in fact, how can a surgeon perform an operation when the chance for survivil is only slight?

True, it is dreadful to decide other peoples' fates.


There is a girl of fourteen, Larissa by name, in Bendet's department. She has a double defect; both the mitral and aortic valves have to be replaced. The aorta is extremely narrow. She was admitted to the clinic three months ago with gravest decompensation, ascitis, and exacerbation of endocardities. An operation was out of the question, but we had to admit her — we feared she would die on the train home. We thought we would treat her until she could withstand the train trip and then discharge her. When she began to feel somewhat better, we pitied her: such a sweet, pleasant girl. Now we can operate on her, but what risks do we run? A huge heart, an enlarged liver... I frightened her father with the risks, and asked him to take her home, but he did not want to do it. And now we cannot postpone it any more... I often see her in the hospital corridor, and a dreadful feeling creeps into my heart — as if I am seeing a child who has been prepared for some sacrificial rite... Horrible. But what can we do?

When we operate on easy patients, then the results are rather good and definite — a mortality rate of 0—2 percent. For the most critical patients, the statistics are 40—50 per cent. That happens because in simple cases, all the organs have a "reserve of resistance " a "reserve of strength" which exceeds loads at rest by three to four times.

However, this does not excuse us. If in one clinic the results are good, then in another, under the same conditions, they are worse, then someone is responsible for it. The problem is that it is rather difficult to compare results — we are dealing with different patients.

It is rather difficult to compare the seriousness of patients in different clinics. And even when different surgeons are involved (there are too many factors influencing the outcome; their quantitative assessment is subjective).

We tried to design a "map of risk" which lists important factors — a total of 12 — and evaluated them in points. For instance, if it is the second operation, then 3 points are added, etc. We count the points and determine the level of risk by the sum of points. For instance, for valvular prosthetics — the first level is up to 4 points, and the third, from 8 to 12. Sometimes you will have 14 or 15 points — this is an "extreme risk" case... It happens that surgeons play tricks sometimes — once in a while they will add a point if there is a formal reason to do so. But I keep an eye on it when they report to me on the patients to be operated upon and state the level of risk. This helps... And I also keep an eye on myself... Unfortunately this system finctions only in our clinic, and we cannot use it to compare our statistics with those of Moscow and Vilnius. True, there are initial points — mortality in normal and critical patients — for instance in the case of repeated operations, as we drew comparisons at the Vilnius symposium...

That is the way we have to justify ourselves in the eyes of strict critics. I am for an accurate assessment. Some resort to convenient camouflage: "The only criterion and judge for a doctor is his conscience." An unreliable judge. A formal system of control is necessary.

Let me add a few more words on death: personally, it became easier for me to live when I saw that it was not dreadful to "pass away."

There is evidence that extremely elderly people die very calmly in old age: they lie down, stop taking food and pass away. This seems quite possible: inhibition of the emotional sphere, the same as in the case of fatal illnesses... But I don't think I will live to such an extreme age. The evidence lies in the other direction.