Public Health and Social Justice

							Using Literature to Teach
 About Death and Dying
      Martin Donohoe
                  Hector Berlioz
   (upon first visiting the dissecting room as a medical
                           student)
• “At the sight of that terrible charnel-house
  – the fragments of limbs, the grinning
  faces and gaping skulls, the bloody
  quagmire underfoot and the atrocious
  smell it gave off, the swarms of sparrows
  wrangling over scraps of lung, the rats in
  their corner gnawing the bleeding
  vertebrae –
                  Hector Berlioz
   (upon first visiting the dissecting room as a medical
                           student)
• – such a feeling of revulsion possessed
  me that I leapt through the window of the
  dissecting room and fled for home as
  though Death and all his hideous train
  were at my heels.”
      Oliver St. John Gogarty
• Turn back now if you are not prepared and
  resigned to devote your lives to the
  contemplation of pain, suffering and
  squalor. . . . Your outlook on life will have
  none of the deception that is the
  unconscious support of the layman: to you
  all life will appear in transit. . . .
      Oliver St. John Gogarty
• You will see . . . the pull of the grave that
  never lets up for one moment, draw down
  the cheeks and the corners of the mouth
  and bend the back until you behold beauty
  abashed and life itself caricatured in the
  spectacle of the living, looking down on
  the sod as if to find a grave.
      Oliver St. John Gogarty
• . . . You can never retreat from the world,
  which is for you a battlefield on which you
  must engage in a relentless and
  unceasing war from which you know that
  you can never emerge victorious.
          Illness and Death
• Exposure
  – Loved ones, friends
  – Patients
  – Self (Lewis Thomas)
• Responses
• Own mortality
        Somerset Maugham
        Of Human Bondage


Doctors see “human nature taken by
surprise, . . . The mask of custom torn off
rudely, showing the soul all raw.”
      Death and Health Care
• Changes in practice over last century
  – Home → Hospital → Home
  – Increased openness
  – Decreased stigmatization
  – Awareness of emotional, social, economic,
    and cultural factors
• Clinical protocols to achieve a “better
  death”; family involvement; hospice; etc.
Improvements in the Care of the Dying

• Symptom management in the dying
  patient

• End-of-life care discussions

• More appropriate use of do-not-resuscitate
  orders
Improvements in the Care of the Dying

• Managing conflicts regarding decisions to
  limit treatment

• Withdrawing intensive life-sustaining
  treatment compassionately

• Facing requests for physician-assisted
  suicide
             Nevertheless

• Studies show need and desire for further
  training in death and dying and end of life
  care among medical students and trainees
       Need for Improvement
• Physicians’ communication with patients
  about advance directives is less than ideal
• Patients often leave routine advance
  directive discussions with serious
  misconceptions about life-sustaining
  treatments
• Significant portion of patients
  misunderstand their options in end-of-life
  care
      Need for Improvement
• Physicians are frequently unaware of their
  patients’ preferences for site of terminal
  care and wishes regarding do-not-
  resuscitate status
• Family members are troubled by the
  amount of pain that they perceive their
  dying loved ones experience in their last
  days.
             Larry Churchill
• “Death [is] a non-technical solution
  problem—[a] problem of the human
  condition. [It] call less for the mystery of
  quantifiable factors in formal knowledge
  than for depth of insight, acuity of
  perception, and skills in communication,
  namely, the sort of expertise which is
  traditionally association with literature.”
Physician Responses to Death
• Sadness/Grief

 – Lewis Thomas, The Youngest Science
   • Intern weeps while presenting case at Morbidity
     and Mortality conference


 – William Carlos Williams, “Dead Baby”
       William Carlos Williams
             Dead Baby
• Describes a funereal scene in which the
  corpse, “a curiosity—/ lays surrounded by
  fresh flowers” in a clean-swept home.

• Apparent order only temporarily conceals
  the powerful emotions of the mourners
Physician Responses to Death
• Fear

 – John Keats, “When I Have Fears”

 – Willliam Carlos Williams, “Danse
   Pseudomacabre”
           John Keats
       “When I Have Fears”

“When I have fears that I may cease to be
Before my pen has gleaned my teeming
brain
. . . then on the shore
Of the world I stand alone, and think
Till love and fame to nothingness do sink.”
     William Carlos Williams
    “Danse Pseudomacabre”

“Christ, Christ! How could I bear to be
separated from this my boon companion,
to be annihilated, to have her annihilated?
How can a man live in the face of this daily
uncertainty? How can a man not go mad
with grief, with apprehension.”
      Michel de Montaigne


“It is not death that alarms me, but dying.”
Physician Responses to Death
• Anger:

 – William Carlos Williams, “Death”
      William Carlos Williams
              “Death”

“He’s dead / the old bastard / . . . / a
godforsaken curio / without / any breath in
it / . . . / . . . Making love / an inside howl /
of anguish and defeat.”
Physician Responses to Death
• Recognition, Acceptance:

 – Anton Chekhov, “Ward Number Six”

 – W. Somerset Maugham, “Sanatorium”
            Anton Chekhov
          “Ward Number Six”
• Dr. Andrew Yefimych accepts suffering
  and death as inextricable, even ennobling,
  aspects of the human condition:
  “To despise suffering [and death] would
  mean to despise one’s own life.”
       W. Somerset Maugham
           “Sanatorium”
• The tuberculous Mr. Chester grows to
  accept the nurturing companionship of his
  wife, whom he had alienated out of
  resentment for the fact that she would live
  while he must die. At the tale’s conclusion,
  he says:
  “I don’t mind dying any more. I don’t think
  death’s very important, not so important as
  love.”
Physician Responses to Death
• Humor:

 – Samuel Shem, House of God
            Samuel Shem
            House of God
• Exhausted interns use sick humor as a
  defense mechanism against the tragic and
  unexplainable deaths they encounter.
• Serves a protective function, allowing
  them to laugh at “what—when seen in
  normal, rather than grotesque terms—
  might make [them] quake or cry.”
             Woody Allen


“I'm not afraid to die, I just don't want to be
there when it happens.”
        Clarence Darrow


“I never wanted to see anybody die, but
there are a few obituary notices I have
read with pleasure. “
 Physician Responses to Death
• Frustration, Futility:

  – John Stone, “Answering the Phone”
             John Stone
        “Answering the Phone”
• Worn down by the death of neighbors,
  patients and friends, expresses his
  frustration and feelings of futility, he “picks
  up the receiver / and say(s) not hello but /
  now what / now what?”
 Physician Responses to Death
• Meditative introspection:

  – Montaigne: “To learn philosophy is to learn to
    die”

  – Rainer Maria Rilke: “Each man bears Death
    within himself, just as a fruit enfolds a stone.”
 Physician Responses to Death
• Meditative introspection:

  – Richard Selzer (“In Praise of Senescence”):
    [One way to confront death is] “to think about
    it, to philosophize, and thereby to peel away
    the fruit to discover the stone within
    ourselves.”
 Physician Responses to Death
• Denial + Insecurity:
  – Richard Selzer (“The Exact Location of the
    Soul”):
    Describes a physician who, uncertain of his
    ability to heal, “pretend(s) . . . that there is
    nothing to fear, that death will not come so
    long as people depend on his authority. [Yet]
    later, after his patients have left, he closet(s)
    himself in his darkened office, sweating and
    afraid.”
        Responses to Death
• Comfort from belief in afterlife:

  – John Donne, “Death be not Proud”
           John Donne
       “Death be not Proud”

“Death be not proud, though some have
called thee Mighty and dreadful, for thou
art not so. For, those, whom thou think'st
thou dost overthrow, die not. Poor death,
nor yet canst thou kill me.”
            John Donne


“When one man dies, one chapter is not
torn out of the book, but translated into a
better language.”
             Woody Allen


“I don't believe in an after life, although I
am bringing a change of underwear.”
 Physician Responses to Death
• Surprise:

  – John Stone, “Death”
             John Stone
               “Death”

“Death / I have seen / come on / slowly as
rust / sand / or suddenly / as when /
someone leaving / a room / finds the
doorknob / come loose in his hand.”
Other Recommended Readings
• “The Gift”—by Allan L. Kennedy
  – Brief story of physician duped by angry wife
    who requests continued aggressive care of
    her moribund husband in order to prolong his
    suffering
• “Medicine,” by Alice Walker
  – Poem on marital devotion and love as
    palliative medicine.
Other Recommended Readings
• “Man is only a reed” (from “Pensées”), by
  Blaise Pascal
  – Cognition and awareness of death ennobles
    man.
• “In the room where my father died,” by
  Joan I. Siegel
  – Death in the context of the modern intensive
    care unit.
Other Recommended Readings
• “Confluence at life’s extremes,” by David
  A. Silverman
  – Short tale on the rewards of geriatrics.
• Essays by Roger Bone
  – Well-known intensivist, who wrote searchingly
    and poignantly of his own death from cancer.
         English Proverb


Death always comes too early or too late.
        Samuel Johnson


“It matters not how a man dies, but how he
lives.”
            Mark Twain


“Let us endeavor so to live that when we
come to die even the undertaker will be
sorry.”
               References
• Donohoe MT. Reflections of physician-
  authors on death: literary selections
  appropriate for teaching rounds, J
  Palliative Med 2002;5(6):843-8.
• Numerous open-access slide shows,
  articles, syllabi, and links available on phsj
  website
 Public Health and Social Justice
             Website

http://www.publichealthandsocialjustice.org
            http://www.phsj.org

              Contact Info:
        martindonohoe@phsj.org