Tragedy Versus Merely Bad News

Taking a deep breath, George began. "Someone backing out of the driveway and running over their child is a tragedy. The Holocaust is a tragedy. People abusing their children is a tragedy. None of those things have to happen. But it's in the nature of things for people to get sick ad die, sometimes of cancer. And the outliers get it young. It's just statistics. Contrary to what you might believe, even I am nowhere near optimistic enough to believe that we can ever have a world in which there's no disease. That's the realm of science fiction.

"George, listen to me for once. James is dying. Don't you care?"

"I hear that he's dying, and of course I care. What kind of person do you think I am that I wouldn't care? I feel terrible that James is dying. I feel terrible for Marla and the girls. And you, I feel terrible for you too, because I know how much he means to you. And I feel terrible for me, because he's become a good friend. All our lives are going to change because of his death. But that's not a tragedy. Don't you see that?"

Nancy Pearl, George & Lizzie (New York: Touchstone, 2017), p. 270

Grief is isolating, but community can help

[W]hile our experience of death was unique, the experience of grieving, of living with grief, of living with death, was universal. I was isolated by my grief for many reasons—my age, the circumstances, the mystery—but I had come to see how everyone is isolated by grief; how grief sends you spiraling inside yourself and how only you can find a way out. And the way out, as my parents discovered, was by finding support and community in other people.

David Kushner, Alligator Candy: A Memoir (New York: Simon & Schuster, 2016), ch. 33.

Why estate planning?

Jackson was forty-seven and in good health, but he had seen a lot of people die when they weren't planning to and had no reason to think it wouldn't happen to him. There were some things you could control and some things you couldn't. The paperwork, as they said, you could control.

Kate Atkinson, One Good Turn (New York: Little, Brown & Co., 2006), p. 36.

Mourning in the public eye

We were a public family, and Jon's murder was a part of the community. This wasn't the same for the other deaths, I realized. No one knew the story of my dad's father, Abraham, when my dad said Kaddish for him. But when my family stood for Jon, they saw the emptiness that was there, the missing person in our family who never returned. 

David Kushner, Alligator Candy: A Memoir (New York: Simon & Schuster, 2016), ch. 16.

No getting around it: death is hard

We cannot remove the pain of loss. Death—whether of patients or of loved ones—will always be difficult. We can create reforms, we can institute policy changes, and we can even write books. But our professional fear and aversion to dying is the most difficult—and most fundamentally human—obstacle in changing end-of-life care. Our grief is the price we pay for caring for the terminally ill, and our aversion is the weight that anchors our inertia and denia.

Pauline W. Chen, Final Exam: A Surgeon's Reflections on Mortality  (New York: Alfred A. Knopf, 2007), Epilogue

How to avoid thinking about death? Denial!

When the chips are down, almost no one wants his life to end, and one good way for the conscious mind to avoid it is for the unconscious mind to deny that it is about to happen. 

Sherwin Nuland, How We Die: Reflections on Life’s Final Chapter (New York: Vintage Books, 1995), p. 229.

Dying can be full of potential

Perhaps all those scientific advancements have given us more than the panoply of treatments and longer life expectancies; they have created an impetus to reappraise how we live. By accepting the reality of dying rather than the misconception, we paradoxically give ourselves the luxury of time. The process of dying can be cast as full of potential rather than as devoid of any final opportunities. There is a chance for real interpersonal reconciliation and emotional expression rather than the hasty symbolic gesture of aggressive treatment.

It is this opportunity, then, and not necessarily the hope of cure, that is the final gift of the medical revolution of the last century.

Pauline W. Chen, Final Exam: A Surgeon's Reflections on Mortality  (New York: Alfred A. Knopf, 2007), ch. 7

Predicting death

We have no reliable way of ascertaining when someone will die. Even with the best medical predictors—physician assessments and statistics—there is often a huge gap between perceived dying and the actual imminence of death.

Pauline W. Chen, Final Exam: A Surgeon's Reflections on Mortality  (New York: Alfred A. Knopf, 2007), ch. 7

Know the illness you face

When we are familiar with the patterns of the illness that afflicts us, we disarm our imaginings. Accurate knowledge of how a disease kills serves to free us from unnecessary terrors of what we might be fated to endure when we die. We may thus be better prepared to recognize the stations at which it is appropriate to ask for relief, or perhaps to begin contemplating whether to end the journey altogether.

Sherwin Nuland, How We Die: Reflections on Life’s Final Chapter (New York: Vintage Books, 1995), p. 143.

M and M as death ritual

Our fingers, no matter how nimble and graceful, are always tangled up with the fate of our patients, and when one of those patients dies, it is impossible to divest ourselves of that sense of responsibility. We torment ourselves with the what-ifs. Perhaps, if we had put that stitch in just a little differently or removed that cancer a little higher up or worked a little longer, then maybe our patient's course might have been different.

. . . M and M requires a public accounting of loss and, in so requires a public accounting of loss and, in so doing, reconstructs the death into an event that affirms a core value of our professional identity: the need to be infallible in a highly variable world. In this way, M and M is like death rituals in other cultures; it seeks to transform death's loss into an affirmative experience.

. . .

By defining death only as the result of errors, we erase the face of our patients and insert our own fiercely optimistic version of immortality.

Pauline W. Chen, Final Exam: A Surgeon's Reflections on Mortality  (New York: Alfred A. Knopf, 2007), pp. 118-19.

Young doctors get little guidance on the dying

As young students and doctors in the midst of profound sleep deprivation and chaotic personal lives centered on work, we are eager to find easy truths or at least comfortable lessons in patient care. Soon enough, however, we discover that death among patients is an inevitable part of our profession. We look to our attending physicians for guidance and we learn that many of them have not only their own difficulties in dealing with death but also little insight into how these attitudes affect the care they give terminal patients. Even our textbooks, usually overflowing with data, provide us with little or no help with the dying.

Thus, without guidance or advice, few of us ever adequately learn how to care for patients at the end of life.

Pauline W. Chen, Final Exam: A Surgeon's Reflections on Mortality  (New York: Alfred A. Knopf, 2007), p. 61.

Despite our best efforts to improve, our apprenticeship system continues to produce doctors who are unable to care humanely for the dying. The attitudes we physicians have toward death become reinforced each and every time we learn from our attendings and then go on to teach others.

Id., p. 73.