Using Literature to Teach About Death and Dying

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 MaughamOf 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 (Goals of Care, Long-Term Care Plan, Code Status) • More appropriate use of do-not-resuscitate orders

Code Status • Full code • DNR • Alternative: “Full code but would not want prolonged intubation or ICU care if there was no reasonable chance of recovery with intact neurological function.”

In Hospital Resuscitation • 43% die despite resuscitative attempts • 39% achieve return of spontaneous circulation but die in hospital • 19% survive to discharge • 11% mild or no neurologic disability • 5% moderate disability • 3% severe disability

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 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

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 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 “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.

Using Literature to Teach About Death and Dying