Is the Fear of Death Rational?

A couple days ago, I had a possible transient ischemic attack. At work, at about 3:30PM, I suddenly noticed this very strong odor, not quite like anything I had ever smelled, but as of something burning. I tried to identify the source, but without any success. The odor would come on in an instant, and then, in a fraction of a second, would be gone utterly.

I figured that it might be a sign of a real problem, likely a stroke, although I had no other symptoms, other than a slight feeling of dizziness or vertigo. So, I left work, and, taking surface streets, drove to the medical center where my personal physician has an office.

As I drove, every minute or two re-experiencing the intense odor for just that fraction of a second, I found myself entranced by the sky, the buildings, the cars and the people in them - everything around me seemed that much more intense. I was seriously considering that I might shortly die, but I felt no fear at all, only a calm satisfaction in having lived, which surprised me a little.

I think that the lack of fear was based partially in the understanding that events would take their own course. I was doing what I could reasonably do to preserve my life, but if it was actually an oncoming major stroke or heart attack, then nothing would likely be sufficient, so, meanwhile, a good time to enjoy what time was left. (A rather close friend had an apparent stroke on the freeway and lasted just long enough to safely pull off onto the shoulder, so I was watching my position carefully in the traffic, recalling his last effort.)

Later on, that night, after the head nurse - my doctor not being in that day - had told me that I was probably going to live, and that I could either get in the urgent care line for at least two hours - and likely catch the flu or something - or go to the ER, which might take even longer, and after I had read through the relevant entries in my PDR at home, I did feel a little panicky, wondering if I should do something more, or just wait to go into a coma in my sleep. I was still getting the odor attacks, and I called a friend to alert her as to circumstances, told her it had been nice knowing her, which she affirmed from her end, and eventually went to sleep.

So, still alive, so far. A few of the mystery smell episodes that morning at work, and some suspicious tightness in my chest that could be psychosomatic - or not - but it did start me thinking about whether my responses were appropriate...

Post 1

Wednesday, January 21, 2009 - 7:39pm

I'm going to say this as nicely as I know how: You fool, go to the hospital!!

Post 2

Wednesday, January 21, 2009 - 7:43pm

"I'm going to say this as nicely as I know how: You fool, go to the hospital!!"

Exactly.

You can still have dying tissue, but don't waste time listening to my advice.

(Edited by Ted Keer on 1/21, 7:44pm)

Post 3

Wednesday, January 21, 2009 - 7:49pm

Get your ass down to the ER. What kind of crappy medical do you have that you can't talk to your doctor on the phone if you need to? A weird neurological symptom is nothing to take lightly.

Post 4

Wednesday, January 21, 2009 - 8:06pm

What everyone else said, Get to a doctor! I've heard that minor strokes respond well to newer treatments when you get them soon. But don't even assume you have a clue what it is - see the doctor.

Post 5

Wednesday, January 21, 2009 - 9:48pm

By now I hope Phil is on his way to the hospital so the following is submitted, not to deter him, but just to give an example of an incident of mine.

When I was about 45 years old I was sitting at my desk at work and began to have the symptoms of a heart attack � all except numbness in my left arm. Anyway, I decided to play it safe and and I left my desk and went to the emergency room where I described my symptoms. The upshot was that they kept me for 3 days, scared to death that they might let a 45 year old out on the street where he might promptly die. As it was, I was the object of some curiosity and the interns were instructed about a marginal abnormality in my heart beat.

Later, when I was 54 I was preparing for a long ocean voyage on a small sailboat so my PCP ordered a treadmill stress test, which I marginally failed. To make sure of the diagnosis they gave me a radioactive stress test where they inject you with radioactive material just at the point of exhaustion. The material concentrates in the areas of the heart that have been most active and by scanning they can see if there is any deficiency. I barely passed this test but was advised it was OK to make the voyage.

Four years ago I was diagnosed with congestive heart failure after having experienced tiredness over quite a long period. In my opinion I should have been diagnosed at least two years prior. Anyway, to address the question of "Is the fear of death rational?" I was told by my doctor that I have a high risk of sudden death. I replied that all my affairs were in order but underneath it I was saying, "Yes! How cool is that?" as if it were a challenge to be met � to maintain a certain state of mind. I have never told anyone of this and I wouldn't tell any of my relatives or personal friends as they might think that this is some sort of macho posturing. I didn't even tell the doc. However, one is perhaps less vulnerable when doing so on this forum where many people have been very open about personal issues, as Phil is. Even if some on this forum think it might be macho posturing it won't affect my relationships.

I don't know how common my attitude is, I only know that a lot of people are afraid of death to the extent that they can't enjoy the time they might have left. I'm sure my attitude is derived, at least in part, by my atheism and for having practiced Zen for about 5 years. I certainly do everything I can to keep going as long as I can, but I'm not preoccupied with morbid thoughts at all. I surely have a fear of a long painful death that one associates with cancer, but that doesn't seem to be in the offing. I seem to have bypassed the stages of denial, bargaining, depression, anger, although it's not like I've been given a definite time limit. The survival rate for CHF is 50% after 5 years from diagnosis.

Btw, congestive heart failure is entirely different from the more usual heart attack.

Post 6

Thursday, January 22, 2009 - 1:02am

Phil, I think fear of death is a rational response at times. That being said, having no fear of death isn't a particularly irrational response either. There's nothing wrong with being ready if you're at a place in life where the prospect isn't frightening anymore.
That being said, Regarding strokes and TIAs, when you initially experience symptoms, you are very much on a clock as far as treatments that can be administered and their potential effectiveness. Generally those treatments are some hard core anticoagulants and you would not be getting them if only a few hours pass from the start of the event. I would also like to note that there is currently NO way prehospital to tell if an event is a stroke or a TIA. So call emergency services and get to the hospital next time. Food for thought, what you describe could also be an aura for a oncoming seizure, in the event that you had one, driving would possibly be a death sentence for yourself or someone else.

Post 7

Thursday, January 22, 2009 - 8:03am

Phil,

I have ischemia. The symptoms that led to discovery of that were episodes that are called complex partial seizures. I have numerous small glionic lesions in white matter. (It makes you wiser. Just kidding.)

Do not take NSAID's such as aspirin or Alleve. See your doctor, who may send you to neurologist.

In 2004 I had an ischemic attack at the colon. They call it the heart attack of the colon. That was a life-threatening situation. Very, very bad pain. Thank goodness for Delauden(?) and modern medicine.

Good luck with this.

~~~~~~~~~~~~~~~~~~~~

"When we are here, death is not come.
When death is come, we are not here."
-Lucretius

(Edited by Stephen Boydstun on 1/22, 10:19am)

Post 8

Thursday, January 22, 2009 - 8:45am

If you want a more humorous diagnosis Phil, I would suggest asking your doctor about aerophagia as it could explain some of your symptoms (mainly the smells). I was sure to check your humor preferences in your profile before disclosing this possibility btw.

On a more serious note it does sound like a nervous system issue (not another fart joke I assure you). Screw the ER, go see a neurologist. My experiences with the ER would suggest they would do a plethora of tests ranging from an EKG to a stress test before even considering sending you to a neurologist and then after several dozen more tests, let you decide what ailment has befallen you.

As for the fear of death I think you are being quite rational in not stressing over what you can neither control nor predict. The steps you have taken to prepare for the worst is admirable, though I would try not to panic my friends and family just yet. A simple I love you or the equivalent would be best.

I have found myself in a number of dangerous circumstances, and my experience with near-death events (though I wasn't in the process of dying) usually led to more of a hightened sense of my surroundings. This could explain your symptoms while driving to the hospital. As far as fear, however, my reactions tended more towards the natural effects of adrenaline and fight or flight responses (usually in the form of act/react/do nothing). To tell you the truth, I'm not too sure what "fear" in itself alludes to but on a seperate note I did attend a conference once where the speaker mentioned that scientists can develop a pill to give to soldiers that inhibits the fear response. I'm not sure how this works but I don't think it's impossible either.

Post 9

Thursday, January 22, 2009 - 8:49am

I should add that the conference I was referring to was on the issue of biological warfare and that is why I said "soldiers". The speaker also mentioned use for people suffering from agorophobia.

Post 10

Thursday, January 22, 2009 - 10:40am

Sam,

For what it's worth, Coenzyme Q10 is used to treat congestive heart failure in Japan. It's not generally prescribed here, as far as I know, but I don't think there are any downsides to taking it. It's a nutritional supplement that's available in drug stores and health-food stores. I've been taking it for years as a general life-extension supplement, which has other benefits.

Now that we have the internet, there's plenty of information about it that you can find online, if you're interested.

- Bill

Post 11

Thursday, January 22, 2009 - 11:00am

It's Dilaudid, Stephen. My doctors usually find it odd that I often accidentally ask for heroin when I really mean morphine. It helps to get the name straight.

Post 12

Thursday, January 22, 2009 - 12:42pm

Bill:

Thanks for the advice. I have taken Coenzyme Q10 in the past as it was recommended by my previous PCP. My current PCP told me that he thought it was optional for me and I have discontinued it. I am currently taking Cardivelol ( a beta blocker), Furosimide, Lisinopril, Aspirin, Lipitor, Potassium Chloride and it just seems excessive to take another one.

Sam

Post 13

Thursday, January 22, 2009 - 4:50pm

Sam,

One of the most dangerous things to do on the internet, is for strangers to medically prescribe to other strangers. That said, Bill means well and his advice for you to look into CoQ10 is good "medical advice" (though we wouldn't call it that literally, because then we go to jail).

Sam, your doctor doesn't need to review evidence of the benefit of what he has prescribed -- because you're already taking those things -- but he or she should be made aware of recent evidence of harm which may or may not befall you (possible harm from taking Lipitor, which is something that may reduce your endogenous CoQ10, which may increase your mortality). Here are a few of things you may want to read and which you may consider to share with your doctor at your next visit:

************

[for the following, go to www.ncbi.nlm.nih.gov/pubmed and type in: 18703694]

Who does not need a statin: too late in end-stage renal disease or heart failure?

Laufs U, Custodis F, B�hm M.

Klinik f�r Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universit�tsklinikum des Saarlandes, 66424 Homburg/Saar, Germany. ulrich@laufs.com

Current guidelines from large randomised trials recommend that all patients with diabetes type 2 or coronary artery disease after myocardial infarction should be treated with statin drugs. However, the recent 4D and CORONA trials show no improvement in mortality in elderly patients with ischaemic heart failure and patients with diabetes and end-stage renal disease receiving haemodialysis with the onset of statin treatment. The survival benefit from statin treatment appears to stem primarily from the prevention of progression of coronary artery disease. In clinical conditions where coronary artery disease does not significantly contribute to the cause of death statins seem to be less effective. In patients at risk for organ damage, statin treatment, therefore, has to be started early in the course of the disease. The effect of statin withdrawal in ischaemic heart failure or in patients with advanced renal disease is not known. On the basis of the available evidence, current statin treatment should not be stopped in these patients.

************

[for the following, go to www.ncbi.nlm.nih.gov/pubmed and type in: 19017509]

Coenzyme Q10: an independent predictor of mortality in chronic heart failure.

Molyneux SL, Florkowski CM, George PM, Pilbrow AP, Frampton CM, Lever M, Richards AM.

Clinical Biochemistry Unit, Canterbury Health Laboratories, Christchurch, New Zealand.

OBJECTIVES: The aim of this study was to investigate the relationship between plasma coenzyme Q(10) (CoQ(10)) and survival in patients with chronic heart failure (CHF).

BACKGROUND: Patients with CHF have low plasma concentrations of CoQ(10), an essential cofactor for mitochondrial electron transport and myocardial energy supply. Additionally, low plasma total cholesterol (TC) concentrations have been associated with higher mortality in heart failure. Plasma CoQ(10) is closely associated with low-density lipoprotein cholesterol (LDL-C), which might contribute to this association. Therefore we tested the hypothesis that plasma CoQ(10) is a predictor of total mortality in CHF and could explain this association.

METHODS: Plasma samples from 236 patients admitted to the hospital with CHF, with a median (range) duration of follow-up of 2.69 (0.12 to 5.75) years, were assayed for LDL-C, TC, and total CoQ(10).

RESULTS: Median age at admission was 77 years. Median (range) CoQ(10) concentration was 0.68 (0.18 to 1.75) micromol/l. The optimal CoQ(10) concentration for prediction of mortality (established with receiver-operator characteristic [ROC] curves) was 0.73 micromol/l. Multivariable analysis allowing for effects of standard predictors of survival--including age at admission, gender, previous myocardial infarction, N-terminal peptide of B-type natriuretic peptide, and estimated glomerular filtration rate (modification of diet in renal disease)--indicated CoQ(10) was an independent predictor of survival, whether dichotomized at the ROC curve cut-point (hazard ratio [HR]: 2.0; 95% confidence interval [CI]: 1.2 to 3.3) or the median (HR: 1.6; 95% CI: 1.0 to 2.6).

CONCLUSIONS: Plasma CoQ(10) concentration was an independent predictor of mortality in this cohort. The CoQ(10) deficiency might be detrimental to the long-term prognosis of CHF, and there is a rationale for controlled intervention studies with CoQ(10).

************

[for the following, go to www.ncbi.nlm.nih.gov/pubmed and type in: 18496257]

Normalization of ejection fraction and resolution of symptoms in chronic severe heart failure is possible with modern medical therapy: clinical observations in 11 patients.

Harinstein ME, Berliner JI, Shah SJ, Taegtmeyer H, Gheorghiade M.

Division of Cardiology, Department of Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA.

This report describes the normalization of left ventricular ejection fraction and resolution of signs and symptoms of chronic and severe heart failure in both male and female patients (mean age 54 years) treated with standard medical therapy. These observations were made in 11 patients with idiopathic dilated cardiomyopathy treated in a single cardiology practice, who had evidence of myocardial "viability" (dysfunctional but noncontractile myocardium that has the potential for improvement in function) as assessed by cardiac magnetic resonance imaging, low-dose dobutamine echocardiography, or nuclear imaging. These patients were treated with standard available therapies including beta-blockers, angiotensin-converting enzyme inhibitors, digoxin, and potassium and non-potassium-sparing diuretics. The average ejection fraction at presentation was 17% +/- 9% which improved to 59% +/- 5%. All patients improved to New York Heart Association functional class I with available therapy. The majority of patients received micronutrient supplementation with coenzyme Q10, vitamin B1, and amino acids, which target the pathways of cardiac metabolism and may aid in the restoration of cardiac function. This case series demonstrates that normalization of cardiac function is possible with standard therapy and the importance of assessing myocardial viability in all patients with heart failure and reduced ejection fraction. Given the unique metabolic needs of the failing heart, the role of micronutrients in combination with standard therapy warrants further investigation.

************

In the least, one should verify that one's doctor is aware of such recent discoveries. After that, the doctor can choose to agree or disagree with the findings or their implications -- but not until after that.

Post 14

Thursday, January 22, 2009 - 6:59pm

Ed:

Thanks for your concern and information. However, there is a distinction between congestive heart failure and chronic heart failure and the condition I have which has nothing to do with atherosclerosis as my arteries are in pretty good shape. My cholesterol levels are also in good shape and the Lipitor is just to get the bad cholesterol down as low as possible, as a precaution. My problem is that the heart muscle itself has deteriorated and this is due to an undetermined cause, but sometimes attributed to exposure to a virus. I also have an implanted defibrillator and a bi-ventricle pacemaker.
Ischaemic or ischemic heart disease (IHD), or myocardial ischaemia, is a disease characterized by reduced blood supply to the heart muscle, usually due to coronary artery disease (atherosclerosis of the coronary arteries).
I did mention that I have taken CoQ10 in the past.

Sam

Post 15

Thursday, January 22, 2009 - 8:45pm

CoQ10 specifically improves mitochondrial function - in some people. Not always. Depends upon the genetics of the particular brand of mitochondria.

Alive, so far. Thanks for the advice. The symptoms have not yet recurred, but, just to make life interesting, I just was run into on my motorcycle about 20 minutes ago, on the way to the library. No major damage to me or the bike so far in evidence, although I do have increasing pain in my left hip, where I hit the pavement. Guy ran a red light and then backed into me - I was stopped behind him - when he suddenly realized his mistake. No place to go. If I had been a little bit sharper, I would have waited, instead of automatically starting forward right after he did.

Post 16

Thursday, January 22, 2009 - 9:23pm

And this time you went to the emergency room?

Post 17

Thursday, January 22, 2009 - 10:30pm

Sam,

Thanks for your concern and information. However, there is a distinction between congestive heart failure and chronic heart failure and the condition I have which has nothing to do with atherosclerosis as my arteries are in pretty good shape. My cholesterol levels are also in good shape and the Lipitor is just to get the bad cholesterol down as low as possible, as a precaution.

Well, that's actually what I was talking about: If the powerful cholesterol-lowering drug Lipitor ends up helping you -- instead of hurting you -- with your heart failure (or folks with other kinds of heart failure), then it won't necessarily help you by reducing your cholesterol. The reason that it won't help you in this way is because low cholesterol is associated with increased mortality in heart failure patients. There are other reasons that Lipitor may help you, but there is also a good reason for concern.

Now, Sam, I'm not your doctor. I wouldn't pretend to be. I'm not even saying that your doctor is wrong, but maybe too unconcerned for this context. After all, I'm just a really, really, really smart guy (that's all). But you -- and your doctor -- should know that having a treatment goal of lowering cholesterol isn't necessarily a good goal for heart failure patients. Hence my concern.

Sam, when you say you have a special kind of heart failure, it's a non sequitur. It doesn't necessarily make any of this less important. In order to show that these benefits or harms don't apply to you, you would have to show how the poor cardiac function that you have specifically, how it makes you immune to the potential benefits or avoidance of harm which I've outlined. There are many ways to have poor cardiac function, but I don't see a reason why that matters here.

Here is more good information -- take it or leave it -- on why it is that I, if I were you, would be concerned with statin meds taken to lower my cholesterol:

*******************
Heart Fail Clin. 2008 Apr;4(2):141-51.

The cholesterol paradox revisited: heart failure, systemic inflammation, and beyond.

von Haehling S, Schefold JC, Springer J, Anker SD.

Charit� Medical School, Campus Virchow-Klinikum, Berlin, Germany.

The pathophysiologic understanding of chronic heart failure has made significant advances over the last decades. Counterintuitively, high levels of plasma cholesterol are associated with better survival, perhaps because plasma lipoproteins are able to scavenge lipopolysaccharide, a cell-wall component from gram-negative bacteria. A number of similar features are present in patients who have sepsis. This article explores the cholesterol paradox in patients who have chronic heart failure and extends this view to patients who have sepsis. Also discussed is the potential of statins, which might be able to exert beneficial effects in both clinical conditions, despite lowering plasma cholesterol values.
*******************
Recap:
Folks with chronic heart failure tend to survive longer with higher -- rather than lower -- cholesterol.

*******************
Am Heart J. 2008 Dec;156(6):1170-6. Epub 2008 Sep 9.

Cholesterol levels and in-hospital mortality in patients with acute decompensated heart failure.

Horwich TB, Hernandez AF, Dai D, Yancy CW, Fonarow GC.

Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles, CA 90095-1679, USA.

BACKGROUND: In chronic heart failure (HF), lower total cholesterol (TC) levels have been associated with increased mortality. However, the relationship between lipid levels and outcomes in acute HF has not been studied. This study investigates the relationship between cholesterol levels and in-hospital mortality in patients hospitalized with acute HF.

METHODS: The Get With the Guidelines-Heart Failure registry prospectively collects data on patients hospitalized with HF. We analyzed data on 17,791 patients admitted between January 2005 and June 2007 at 236 participating hospitals who had TC levels recorded. Baseline patient characteristics, treatment regimens, and in-hospital mortality were examined by TC level (mg/dL) quartiles (Q) as follows: Q1 (TC < or =118), Q2 (TC 119-145), Q3 (TC 146-179), and Q4 (TC > or =180).

RESULTS: Mean TC level was 150 +/- 47 mg/dL. Patients with lower TC were older and had higher prevalence of ischemic heart disease. Of the patients, 46% were on a lipid-lowering drug, including 58%, 50%, 43%, and 34% of patients in TC Q1 to Q4, respectively. In-hospital mortality in TC Q1 to Q4 was 3.3%, 2.5%, 2.0%, and 1.3%, respectively (P < .0001). On multivariable adjusted analyses, each 10-mg/dL increase in TC level was associated with 4% decreased risk of in-hospital mortality (odds ratio 0.96, 95% CI 0.93-0.98).

CONCLUSIONS: In patients hospitalized with HF, lower TC levels independently predict increased in-hospital mortality risk. Further evaluation of optimal cholesterol levels and influence of lipid-lowering medication use on outcomes in this population is warranted.
*******************
Recap:
Folks with acute heart failure tend to survive longer with higher -- rather than lower -- cholesterol.

Ed

(Edited by Ed Thompson on 1/23, 4:33am)

Post 18

Friday, January 23, 2009 - 6:32am

What a bit of bad luck Phil. Some of the near-death experiences I was referring to were on a motorcycle as well. Unfortunately it isn't always enough to anticipate the actions of other drivers as they always seem to create new ways to test the skills of bikers. I'm glad that your bike and of course you as well have emerged from your incident with little damage.

Post 19

Friday, January 23, 2009 - 9:21am