CHAPTER 1
Aloha — Sharing the Breath of God
George, a fifty-eight-year-old native Hawaiian pig farmer, suffered a devastating heart attack. He had been in the intensive care unit at the hospital now for three days. His condition was serious and not getting better. He lay in a strange, uncomfortable hospital bed from which he would never again rise — the so-called deathbed. George's life had changed so quickly and unexpectedly over three days from surprise to disbelief to denial and now fear. He wondered what would happen next in this nightmare.
I was part of the team of doctors, nurses, and technicians that had done everything that modern medicine could do to restore and prolong George's life. Unfortunately, it was not enough. George's heart muscle was severely damaged from the heart attack and was now terminally weak. George sat uncomfortably upright in his bed, severely short of breath. He was wearing a special oxygen mask to try to push extra oxygen down into his lungs and into his circulation. The heart attack had caused fluid to build up in his lungs and make breathing difficult. He felt like he was drowning. His agony was getting worse each day. He was exhausted and wanted to sleep but feared it would be his last sleep. His fear was appropriate. He had copious amounts on sweat on his forehead and strained wrinkles on his face. The primary diagnosis on the front page of his medical chart was acute myocardial infarction with severe congestive heart failure and shock.
We treated his congestive heart failure aggressively with multiple intravenous medications. These included medications to maintain his blood pressure and keep his heart rhythm regular, and diuretics to reduce the fluid in his lungs. However, this could only give him minimal temporary relief from his agony. The damage done to his heart from the heart attack was irreversible and severe. Certainly, his medical situation was complex but not dissimilar to many patients I had seen with these similar massive heart attacks, many of whom had died in front of me. Yet there is always hope, because still many patients do survive such devastating problems.
As George's heart became weaker, the blood flow to his internal organs became suboptimal. As the kidneys weakened from lack of oxygen, toxins accumulated in his blood. This clouded his thinking. Lack of blood flow also caused his liver to malfunction. This further increased the fluids in his lungs to the point where he could not lie flat because that made his breathing problem worse. As George sat up in the hospital bed, he used every muscle in his chest to struggle for each breath of air. He was very restless. His fatigue grew worse each day. His eyes were bloodshot from all his bodily stress. Because of his severe dyspnea (shortness of breath), his conversations with me became condensed to simple words and expressions of discomfort. Even with a special oxygen mask over his mouth and nose, he continued to struggle for each breath. Every cell in his body screamed for more oxygen. But the only way to get the oxygen into his body was through the lungs, and his lungs were saturated with fluid.
George grew more and more tired with each breath. Each single breath was so difficult yet so precious. Each breath separated his life from death. With his struggle to breathe, he realized how much he still wanted to live. He loved his life and wanted it to go on forever. This is a natural desire since we know nothing different or what the future holds. For George, like most of us, this was the most fearful moment of his life.
In a short, quiet moment between treatments, George remembered how easily he'd breathed a few days earlier before the heart attack and how he'd taken that for granted. He had had only mild breathing problems when he had to do some heavy work on his farm. That seemed like a lifetime ago after three days of stress and misery. His sole wish now was only to breathe with ease in the presence of those he loved.
George had been a regular patient of mine for many years. During those ten years, he also became a good friend. George was a large, muscular Hawaiian man with dark brown skin. He had short, curly dark hair with just a little bit of distinguishing gray. He had large, compassionate brown eyes. His hands seemed enormous to me, yet in spite of his hard work, they remained incredibly soft. He had a deep, resonant voice and a genuine, kind smile. He was truly a gentle giant.
George's wife's name was Rosie. She was half-Chinese and half-Filipino and half the size of George. She was physically much the opposite George. She was small and had delicate facial features. Although she was small, she had enormous strength of character. They complemented each other. This made George and Rosie a good couple.
George and Rosie had met each other as teenagers and had been married for thirty-eight loving years. They were very devoted to each other. With their combined talents, they worked very hard on their pig farm on the west side of Oahu. They made only minor profits. Each day was a financial struggle, but it did not matter to them because they had each other. They had spent every day of their married life together and happy. That was what was important to them.
George and Rosie were grateful to have a lovely daughter, Kai, short for Kailani. They had wanted children for many years but were told by the doctors that they could not. Fortunately, doctors are often wrong. After many childless years of marriage, much to their surprise, they were blessed with a baby girl. Her name, Kailani, means "gift from heaven" in Hawaiian.
I had known Kai since she was born. I was at Kai's first birthday party. In Hawaii, this is often a big celebration for the family and is called a baby luau. All the extended family and friends are invited. Everyone, whether family or not, becomes an unofficial auntie or uncle. Because Hawaiians often do not have too much money, the celebration is held outside around the garage. Everyone brings enormous amounts of food, and local musicians play Hawaiian music outside all day with their guitars. In Hawaii, the custom is to eat until you sleep. This was one of my first baby luaus. I did eat a lot delicious local fish, poi, rice, and coconut pudding, and I did sleep well that night with Hawaiian music still resonating in my head.
Kai was a beautiful young girl. She had long black hair, big brown eyes like her father, soft brown skin, and a big smile and delicate feminine features like her mother. She always looked like a princess. She frequently came to the hospital with her father when he had checkups with me. She liked talking to my nurses, who always entertained her while I was examining her father. She was a real chatterbox.
At the time of her father's heart attack, the little Kai was now eighteen years old. How quickly she had transitioned from playful child into a lovely young woman. Kai was now married and eight months pregnant. It seemed like just a second (or a breath) ago I was at her baby luau.
Both Rosie and Kai were ever present at George's bedside while he struggled to breathe. With anxious eyes, they tried to comfort George, but at the same time, they were very concerned. They tried to hide this concern with a half smile, but in private there were many tears of sadness shared between them because of George's condition.
George and I discussed his condition and therapeutic options many times over those three days in the intensive care unit. Rosie was always at his side holding his hand and trying to give encouragement. She and George did not understand many of the medical terms or treatments, but they trusted in me to do what was best. I explored every medical and possible surgical option with him. I really wanted to reverse his condition. But my optimism was tempered by the reality that George was not responding to medications and that he was getting worse each day.
I ordered an echocardiogram test of his heart. This is a painless sound wave picture of the heart done easily at the bedside in the intensive care unit. The results demonstrated George's heart to be very enlarged and severely weak. A measurement of muscle function called ejection fraction was less than 10 percent. (Normal ejection fraction is more than 60 percent.) Knowing this number, I knew that George's life was limited and my therapeutic options were also limited. George was disappointed when he heard this technical diagnosis. He had many questions. After careful consideration, George chose not to be resuscitated or put on a ventilator should his condition suddenly get worse. He did not want his life artificially prolonged in agony if there could be no reversal of his underlying problem.
This was a very hard decision for George. He loved his family. When he made this decision, it was a very sad moment, yet at the same time, he knew what his heart was telling him. I much respected his thoughtful decision but at the same time continued to do everything possible to try to reverse his terminal medical condition. Although I respected his wishes, I also never gave up hope. George did not need any more scientific studies to tell him that he really was dying. His moment of confrontation with reality had come. He accepted it with grace and was now ready to deal with it. His fear was lessened.
This moment of confrontation with reality usually comes unexpectedly. Mostly dying people never get past the fear of it. There is never a good time for illness or death. We all know this moment will come, but we mostly deny it. Acceptance of death over fear can actually be liberating, as it allows one to focus on what is important in life.
Death was the last thing on George's mind three days earlier when he'd felt well. George had reluctantly reached the stage of acceptance of dying over a brief period of three days. The extreme difficulty of breathing had forced that reality. As George went through the stages of dying from denial to fear to anger and eventually acceptance, he did gain some peace of mind. He became very focused. While gasping for every breath, George became thoughtful about his last wishes. He expressed these wishes to his family and me. If possible, he simply wanted to stay alive long enough to share aloha with his yet unborn first grandchild.
Knowing George's wishes, I would work as his partner to do everything possible short of a ventilator to keep him breathing and alive. What I did not know at that same moment was that Kai had developed unexpected premature labor. Suddenly she was also in the hospital just down the hallway from her father's room. I would also be involved with her care.
Kai had not had an easy pregnancy. She had intermittent high blood pressure. Her heartbeat was irregular. She was also retaining fluid. Her ankles were markedly swollen, and she also had a few crackles of fluid in her lungs. Her breathing was slightly labored. Her blood sugar was also moderately elevated. All these things worried me.
I worked with her obstetric doctor to consult on her heart problems. We both feared that she was developing a condition called eclampsia. This causes very high blood pressure, kidney failure, heart failure, strokes, seizures, and frequently, sudden death. It is a rare condition but occurs more commonly in young women with their first pregnancy. There was also a history of death during childbirth in George's family; his mother had died suddenly during his own birth. It was caused by a seizure with high blood pressure and eclampsia. Now with both George and Kai in the hospital together, a dark cloud hung over the family. The darkness is always the greatest just before the storm. George, Rosie, and Kai would all need faith and luck to weather this storm.
During this stressful time, I reflected on what George had said earlier how he wanted share aloha with his yet unborn grandchild. I fondly remembered how George had taught me the real meaning of aloha.
Years earlier, when George had first become my patient, I would greet him with a smile, handshake, and a friendly Hello and How are you? This is my usual greeting. One day when I saw George for his routine visit, he interrupted my usual greeting. He said, "Today, Doctor, I am going to teach you how to share aloha!"
I was very familiar with Hawaiian word aloha. It is a very special multipurpose word used frequently in Hawaii to express hello, good-bye, and love. But I was a bit puzzled by his use of the word share. I asked George to explain further.
George explained that:
Aloha is actually two words: Alo and Ha.
Alo means to share.
Ha means the breath of God.
Therefore, aloha means to share the breath of God.
According to Hawaiian legend, hello, good-bye, and love expressed as aloha are all part of God's breath given to us to use wisely.
George further explained the right way to physically say aloha.
First, one takes in a deep breath and with appreciation slowly says the first word, Alo, with resonance deep within the chest. Then shortly thereafter at just the right moment while exhaling, one says the second word, Ha, with clarity and determination. As Ha is being said, let the air in your lungs be gently expelled through the open mouth to sound like the wind. With the lungs near empty, one then takes in a new breath through the nose, again appreciates it in the lungs, and slowly exhales it through the nose in silence.
However, before saying aloha, George explained, "It is important to first share aloha. This is a physical action before the speaking the word, which gives it special meaning and energy.
Sharing aloha is in done in relative silence. Instead of embracing to show love, Hawaiians face each other and gently join their foreheads together until their noses are in close proximity. Then they just breathe together in silence through their noses and exchange each other's breath through their nostrils. This is an ultimate act of love and respect.
The ancient Hawaiians realized that just like the seasons of the year, the winds on the mountains, or the waves of the ocean, the words hello, good-bye, and love represent parts of a continuous flow of energy rather than being isolated events.
George continued, "Love has always been, is present, and will always be. We are reminded of this with God's words that we hear only in silence."
Lastly, George slowly and wisely said, "To keep love alive and flowing, we just need to share aloha and appreciate it each moment."
What could express love more than purposefully sharing the breath of God with each other? With George's teaching, I got a new perspective of aloha.
Shortly after George's instruction, he and I shared aloha for the first time. Before saying aloha, we gently joined foreheads and had our nostrils side by side. I could feel his strong presence and the power of his breath. I overcame my unfamiliarity and cultural difference to just go with the flow of energy. I felt close to George. I also felt close to God. Sharing aloha set the stage for sharing love and respect. The ritual made our doctor-patient visits much more productive and respectful. We both felt more alive and honored.
George had learned this greeting of aloha from his Hawaiian ancestors. For him, it was quite natural. When George shared aloha, he was always humble. George was always fearful that he smelled of pigs from his farm. He was always apologizing. Maybe I had a smelling defect, but I never could smell pig scent on him. All I could smell was love. With each shared breath of aloha, we literally became closer friends.
But now, George was terminally ill, and Kai was anxiously in labor. What would be my role in trying to help both of them? I felt a bit nervous and wondered if I was up to the task. I had a silent meditative moment and asked God for help.
Kai was in her hospital bed surrounded by technological monitoring. We also were able to monitor her baby's heartbeats and movement. Her blood pressure was only slightly elevated. It was controlled with medications. Her heart remained stable. We gave her intravenous magnesium sulfate to reduce the risk of seizures. Kai's kidney function remained stable. The baby's heartbeat was also strong and fast. All was going well.
