Notes toward an advance directive

Omar Nabil Metwally, MD

I have started planning my death the way other people plan a kitchen remodel: with a folder, a rough budget, and a growing list of contractors I will never hire again.

This is not morbid. I want to be clear about that, because my family will read this and worry, and my wife will not read it and worry anyway. It is the opposite of morbid. It is the single most practical thing I have done since I learned to check the expiration date on the milk before buying it. I am a physician. I am about fifteen years out of medical school. I have spent a measurable fraction of my adult life inside American hospitals, and I have come out the other side with one conviction so clean and so bright that I can hold it up to the light and see no flaw in it anywhere:

Never again.

Let me tell you what a hospital is, in case you have only ever visited one, which is like saying you have visited the ocean because you once stood in a parking lot near it.

A hospital is a building in which it is impossible to sleep. The bed inflates and deflates itself on a schedule known only to the bed. Something beeps. Something else beeps in answer, and the two of them carry on a conversation across the hallway all night like dogs. At four in the morning a kind person arrives to take your blood, not because anything will be done with the result before nine, but because four is when the blood is taken. A television bolted to the ceiling plays a cooking show no one chose. The hospitalist changes every seven days, like a weather front. The nurse is excellent and has eight other patients, three of whom are screaming and one of whom is you. On day three someone orders a scan to explain a finding that was caused by day two. On day five you leave with a discharge summary longer than the Finnish constitution and a new diagnosis you did not have when you arrived.

And then, on the far side of all of it, there is a person whose job title is Risk Management, who has never touched a patient and whose entire function is to make sure the building is never the one holding the bag. I have written elsewhere about the sixteen hours. I will say only this: the day you start wishing broken hips on risk managers, out loud, in a family group chat, is the day you have officially graduated from American healthcare. There is no ceremony. You just know.

Nobody chooses any of this. It accretes. It is the clinical equivalent of a junk drawer, and the horrible part, the part that took me years to admit, is that I helped build it. I have ordered the four a.m. labs. I have written the summaries. I have stood at the foot of the bed at seven in the morning and said “we’re going to keep you one more night, just to be safe,” and I meant it, and I was wrong.

Here is what fifteen years taught me, and I am giving it away for free, which is already more than the system has done for anyone: the surest way to stay well, physically and mentally, is to stay out of the hospital. Too much of what happens inside one is where people go to get sicker, suffer, and die. Not always. Not everyone. I still send patients there every week and I will keep doing it, because there is a real category of problems for which the alternative is worse, and when you are in that category you go, and you go now. That is not what this essay is about. This essay is about everything else, which is most of it, and about one body in particular, which is mine. Nothing here is advice. It is a man describing his own exit.

And when I truly do need healthcare, the kind where a doctor sits down, I will book a flight to a country that has an actual working system. I have been on the receiving end of that kind of care, and I did not know what to do with my hands. Someone looked at me. For minutes. There was no portal. There was no “I’m going to step out and you’ll hear from someone.” I kept waiting for the catch and the catch was the bill, which I paid out of pocket with the kind of money I keep in the glovebox for parking.

When I was in my twenties I spent a summer in Finland measuring trees, and I came away with two permanent injuries: a lifelong respect for a country that treats a sauna as public infrastructure, and the inability to ever again find it normal that a sick person should have to fight. In Finland the hospital was a building where sick people went and then, after a while, left. That is the whole trick. We have made it sound exotic.

So here is the plan. When the diagnosis comes, and it will, I have read the actuarial tables, this is what I intend to do, in order. I am talking about the end, the real one, the kind every clinician recognizes from across the room. Not the first chest pain at fifty. I know the difference. It is the one thing the training is reliably good for.

1. I will not be admitted. I will be a visitor. I will keep my coat on, the way you keep your coat on at a party you are planning to leave. If anyone says the phrase “just to be safe,” I will understand it as the sound of a door closing, and I will walk through it in the other direction.
2. If it is the fast kind, the stroke or the heart attack, I will crawl under a warm blanket and thank God, sincerely and for the first time in years, that I do not have to die in a hospital. A blanket. Think about how low the bar is. Think about what it says that the blanket wins.
3. If it is the slow kind, I will go home. I have a garden. I grow tobacco, which is a wonderful plant to grow when you have decided to stop pretending you will live forever, and tomatoes nobody asked for, and I have a four-year-old who narrates all of it. There is a puppy. There is no television bolted to the ceiling. Nobody comes at four in the morning except the puppy, and he does not want my blood, he wants the yard.
4. I will book a flight. Somewhere a doctor still sits down. I am not particular about which somewhere. I have a short list, and the list is organized not by survival statistics but by a single question: in this country, when you are dying, does anyone look at you?
5. I will say no. This is the hard one. Physicians are terrible at it. We know exactly which interventions buy a week in exchange for the week, and we accept them anyway, because saying no in front of your colleagues feels like quitting the team. I am putting it in writing so that I cannot pretend later that I didn’t know. I knew. I know now. No.
6. I will end in a sauna. If it is up to me, and the entire purpose of this document is that it should be, then it ends in a sauna, at a temperature that would alarm a cardiologist, with a lake outside doing what lakes do, and someone I love sitting on the lower bench complaining that it is too hot. That is a death. The other thing, the inflating bed and the beeping and the cooking show, is a billing event.

My wife, who is the smartest person I have ever known, has never read anything I have written, and she is not going to start with this. Which means my advance directive will be executed by someone who has not read it. I thought about this for a long time and decided it was fine. That is how most of American healthcare is practiced, and I would hate to be inconsistent at the very end.

So I’m saying it here, out loud, where my siblings will find it and forward it to her with the subject line “did you see this”: When it’s time, don’t take me to the hospital. Take me to the airport.

STAT. It’s hospital for “now.” It is the only word from the place I intend to keep.