The DIT’s guide to death

Our society is not very comfortable discussing death. Nevertheless, on a long enough timeline everyone is affected by personal loss. The years before we know what it means to grieve are a time of blissful ignorance which some get to enjoy till quite late in life. However, as doctors we develop intimacy with the realities of death quickly – whether we are ready for it or not.

Many interns arrive on the job with direct experience of death, in fact many people choose medicine as a result of experiencing the loss of a loved one. I have the utmost respect for those who have taken their grief and chosen to channel it positively, spending their lives attenuating suffering and comforting others through this inevitability. For those of us lucky enough to have delayed our acquaintance with death, internship can be the first time we have had to grapple with mortality – a fact not often acknowledged. We may talk about the end of life in a detached and professional way – drugs for comfort care, or filling out a death certificate correctly (that one gets a lot of airtime). But through medical school and pre-vocational training I only recall discussing our own mortality once when a beleaguered palliative care physician handed out photocopies of Sidney Nolan’s 1950 Burke Lay Dying and asked us to imagine how it would really feel to be in the desert alone with no hope of rescue. I drew his ire by pointing out I thought Burke should really have dug down for water under the roots of the huge tree he was dying beside. Not really the objective of the exercise, but what’s the point of being Australian if you can’t demonstrate bush survival skills?

We teach medical students sociocultural complexities like communication, consent, social determinants of health, and professionalism, but reflecting on mortality is considered an overreach – too personal. Even though I couldn’t help being a smartarse, I recognise that that palliative care physician was doing me a big favour by teaching me empathy for those who are out of options by breaking down the mental barrier between the dying patient and the young healthy doctor.

Dr Paul Kalanithi’s memoir When Breath Becomes Air describes his vertiginous spiritual and psychological shift when he was diagnosed with metastatic lung cancer at 37 years old, less than 12 months from becoming a fully qualified neurosurgeon. He describes an evolution in his relationship with death, and it is one I think most training doctors go through; from his first brush with mortality seeing two premature twins pass away on the first night of his internship, to the inevitable cognitive distance that develops between the dying patient and one’s self over time as a result of repetition and self-preservation. He acts as an “ambassador of death” for families when their loved ones have severe traumatic brain injuries. When he himself must confront his own premature demise he can no longer insulate himself from a deep understanding of what his patients past and present go through, but realises we must all come to such an understanding eventually.

I’d petition for When Breath Becomes Air to be added to the internship reading list along with Marshall & RuedyÕs On Call: Principles and Protocals and Samuel ShemÕs The House of God. It is easy to say Dr KalanithiÕs book will have the positive effect of increased empathy and compassion, but this is the easiest and least controversial message. The real truth is that we will have a relationship with the end of life that will fluctuate with time and experience. We would be used up very quickly if we grieved for each and every patient we encounter. Reflection on our own experiences and listening to the stories of others puts us on the path to more thoughtful and self-aware practice as we continue our journey both as doctors and as emotional beings.