Final Exam
Author: Pauline W. Chen

Synopsis

This book tackles a glaring failure of medical education-how it inadequately prepares doctors to care for their dying patients (page xiii). It explores the anomalous situation whereby a profession ‘intricately associated with mortality‘ provides very little guidance and support to enable its practitioners confront death in their routine practice (pages 61 and 79). The author, a surgeon, argues that many doctors suffer from a ‘professional fear and aversion to dying’, and this unease is a major hinderance to how they provide end-of-life care (page 217). In a very forensic approach, the author identifies the reasons medical students develop a distorted perception of death, and she demonstrates how the culture of medical practice further entrenches this warped attitude. She however proffers many helpful solutions to remedy the deficiencies she describes.

The book does a very good job of identifying the factors which ingrain faulty notions of death in doctors. One example she pointed out is the very unrealistic expectation of medical students of how much they can actually do, when they become doctors, to cure their patients (pages 33-34). This, combined with the false sense of power over death they acquire from their cadaver dissection lessons, instils in them a spurious sense of invincibility. The author graphically illustrated how the gruesome practice of dissecting the dead, whereby ‘every cavity is probed, every groove explored, and every crevice pulled apart’, erodes the emotional impulses that otherwise normal people have towards death and dying (pages xiii-xv and 17-18). The book also demonstrates how, along with the frequent accompanying use of black humour, cadaver dissection engenders in medical students a ‘systemic depersonalisation of dying. The end result, the author contends, is that medical students suppress their ‘fundamental and very human fear of death‘, and ignore or avoid their profound unease and ‘deeply rooted angst‘ when they face it (page 8). By so doing, she said, doctors end up separating their emotional from their scientific selves. 

A major concern the book addressed is how the culture of medicine itself serves to corrode the normal instincts of doctors towards death. This starts as soon as new doctors come face-to-face with the reality that ‘death among patients is an inevitable part of our profession’ (pages 60-61). This realisation, the author said, not only dispels their wrong assumptions about their power to cure all their patients, but it also instils in them an anxiety about death. The book argues that this anxiety is further exacerbated by the imbibed rituals and the hidden curriculum of medicine which ‘handicap us and foster a false sense of infallibility‘ (pages 89 and 97). A specific ritual she highlighted in this regard is the morbidity and mortality (M and M) meeting which, by viewing death ‘wholly through the lens of personal responsibility‘, may actually prevent ‘the very best care for our patients’ (page 119). These medical practices eventually create a new ‘moral paradigm‘ of ‘detached concern, secure uncertainty, and humanistic technology‘, in which new doctors become ‘unable to care humanely for the dying’ (pages 45 and 72-73).

Expectedly, palliative care was a major theme in this book about death. The author was very critical of the tendency of physicians to act to preserve life at all costs, the so-called ‘doers paradise‘ where physicians ‘battle away until the last precious hours of life, believing that cure is the only goal‘ (page 148). The book shows how this denial of impending mortality impels doctors to ‘push for more therapy right up to and through the most terminal stages of a disease’ (pages 164 and 170-171). It identified several drivers for this vigorous treatment paradigm, one of which is the difficulty both physicians and families have of knowing ‘when to stop treating and start palliating‘. The author said this difficulty may be mitigated when doctors realise that death is a process rather than ‘a certain, discrete event completely distinguishable from life’. This enlightened definition of death may therefore prevent the ‘hasty symbolic gesture of aggressive treatment‘, and enable ‘real interpersonal reconciliation and emotional expression‘ (page 158-161). The book also addressed many other aspects of palliative care, including the perennial difficulty doctors have in broaching the subjects of death, and of breaking bad news.

The author’s personal encounters of death inform the strong opinions she conveys in the book. One of her most transformative experiences concerns Max, an infant born with gastrochisis, who endured, but did not survive, the extreme measures his doctors took to keep him alive. She reflected, rather regretfully, on how her team ‘were trapped in a trajectory of our own making’ and ‘continued to ascend along the interventional spectrum until we had made mincemeat out of the object of our care’ (pages 149-156). She however also related excellent practice concerning death, for example when she described her attending surgeon’s humane approach to the family of a man dying on the intensive care unit; the attending broke the familiar rituals by gently explaining the dying process to the patient’s wife whilst holding her hand, and, instead of rapidly departing, he lingered with the family. This experience altered her own practice, saying ‘I stopped slipping away from my dying ICU patients and their families. Instead…I would bring them to the their loved one’s bedside and describe the characteristic last breaths of the dying. I would touch family members, embrace those who looked particularly lost, and tell them of the final comfort of their presence’ (pages 98-101). 

The author made several recommendations to enable physicians change their mindset about death and dying. She urged them, for example, to acknowledge their own mortality if they are to adequately address the concerns of their dying patients, and to alleviate ‘the suffering which results from a loss of meaning and purpose‘. She encouraged physicians to help their dying patients by just being present for them, and by giving weight to their experience (page 207). Citing the inspiring physician and patient Hacib Aoun, she advised doctors to put humaneness above technical knowledge, and to focus on the patient more than the disease,arguing that this is especially important where there are limited therapeutic options (pages 132-137). She quoted Sigmund Freud when she cautioned doctors to avoid the ‘illusory immortality‘ that comes with witnessing the deaths of others, a practice which may engender professional arrogance and ‘selfless feats of medical heroism‘ (pages 194-195). The book also made many interesting references to literature such Leo Tolstoy’s The Death of Ivan Ilyich, the iconic fictional account of the irrationality of death (page 193).

Opinion

This book is a deep reflection on how the attitude of physicians to their own mortality affects the care they give their patients. Relying on personal experience and research references, the author details the reasons behind the anxiety doctors have about death, and how this unease limits their ability to care for the dying. She supports her views with illustrative cases and well-considered arguments, and she offers cogent solutions to the problems she highlights. Her recommendations for a more sensible attitude to dying are particularly helpful, as are her advocacy to reform medical training to reflect the inevitable mortality that accompanies clinical medicine. The prose is brilliant, particularly when she related the life history of her cadaver. 

Overall assessment

This account of a surgeon’s reflections on mortality is profoundly moving. The book highlights a subject that is central to clinical practice but often overlooked. The author addresses the root causes of the dilemma doctors face when confronting death, and she proffers helpful suggestions which have the potential to improve clinical practice. I recommend the book to all doctors.

Book details

Publisher, Place, Year: First Vintage Books, New York, 2007
Number of chapters: 9
Number of pages: 267
ISBN: 978-0-307-27537-0
Star rating: 5
Price: £16.50