Using Literature to Teach About Death and Dying

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Using Literature to Teach About Death and Dying

• Martin Donohoe

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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. .
  . .

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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.

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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.

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Illness and Death

• Exposure
• Loved ones, friends
• Patients
• Self (Lewis Thomas)
• Responses
• Own mortality

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Somerset MaughamOf Human Bondage

• Doctors see human nature taken by surprise, . .
  . The mask of custom torn off rudely, showing the
  soul all raw.

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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.

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Improvements in the Care of the Dying

• Symptom management in the dying patient
• End-of-life care discussions
• Appropriately use of do-not-resuscitate orders

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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

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Nevertheless

• Studies show need and desire for further training
  in death and dying and end of life care among
  medical students and trainees

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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

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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.

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Larry Churchill

• Death is a non-technical solution problema
  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.

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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

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William Carlos WilliamsDead 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

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Physician Responses to Death

• Fear
• John Keats, When I Have Fears
• Willliam Carlos Williams, Danse Pseudomacabre

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John KeatsWhen 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.

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William Carlos WilliamsDanse 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.

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Michel de Montaigne

• It is not death that alarms me, but dying.

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Physician Responses to Death

• Anger
• William Carlos Williams, Death

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William Carlos WilliamsDeath

• Hes dead / the old bastard / . . . / a
  godforsaken curio / without / any breath in it /
  . . . / . . . Making love / an inside howl / of
  anguish and defeat.

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Physician Responses to Death

• Recognition, Acceptance
• Anton Chekhov, Ward Number Six
• W. Somerset Maugham, Sanatorium

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Anton ChekhovWard 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 ones own life.

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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 tales
  conclusion, he says
• I dont mind dying any more. I dont think
  deaths very important, not so important as love.

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Physician Responses to Death

• Humor
• Samuel Shem, House of God

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Samuel ShemHouse 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 whatwhen seen in normal, rather than
  grotesque termsmight make them quake or cry.

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Woody Allen

• I'm not afraid to die, I just don't want to be
  there when it happens.

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Clarence Darrow

• I never wanted to see anybody die, but there
  are a few obituary notices I have read with
  pleasure.

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Physician Responses to Death

• Frustration, Futility
• John Stone, Answering the Phone

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John StoneAnswering 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?

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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.

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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.

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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.

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Responses to Death

• Comfort from belief in afterlife
• John Donne, Death be not Proud

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John DonneDeath 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.

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John Donne

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

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Woody Allen

• I don't believe in an after life, although I am
  bringing a change of underwear.

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Physician Responses to Death

• Surprise
• John Stone, Death

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John StoneDeath

• 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.

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Other Recommended Readings

• The Giftby 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.

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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.

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Other Recommended Readings

• Confluence at lifes 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.

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English Proverb

• Death always comes too early or too late.

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Samuel Johnson

• It matters not how a man dies, but how he
  lives.

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Mark Twain

• Let us endeavor so to live that when we come to
  die even the undertaker will be sorry.

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References

• Donohoe MT. Reflections of physician-authors on
  death literary selections appropriate for
  teaching rounds, J Palliative Med
  20025(6)843-8.
• Numerous open-access slide shows, articles,
  syllabi, and links available on phsj website

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Public Health and Social Justice Website

• http//www.publichealthandsocialjustice.org
• http//www.phsj.org
• Contact Info
• martindonohoe_at_phsj.org