Merely mortal

DECEMBER was a somber month for our family. Our brother-in-law -- a strapping picture of health just a year ago -- lost his 10-month battle against cancer. But in one respect, we all agree, he was blessed. Until his final, morphine-clouded days, he remained his own man. Guided by first-rate physicians yet never governed by them, he received state-of-the-art treatments with hope and, at the same time, eyes wide open. He tracked his blood tests and sometimes read his X-ray reports before his doctors did. Finally, when he knew his end was near, it was he who stopped his chemotherapy. Roughly a week later -- and only 2 1/2 weeks after hosting our family Thanksgiving -- he died.

Exercising personal autonomy around one’s death is no simple matter today -- especially in settings of ever-more sophisticated and fragmented medical care. As Pauline W. Chen points out in “Final Exam: A Surgeon’s Reflections on Mortality,” the medical profession bears a good measure of responsibility for this dilemma. But “Final Exam” is neither an angry rant nor a bloodless treatise about medicine’s failings. By sharing stories of her own maturation into a healer as well as a technically skilled doctor, Chen in this fresh and honest memoir engages and educates on many levels. At the same time, the author’s principal goal -- to hold herself and fellow physicians accountable for providing better end-of-life care -- is ever in view.

The book opens with a frank confession. When choosing her career, Chen writes, “What I did not count on was how much death would be a part of my work.” In graceful, lucid prose, she then narrates key events through which medical students and trainees first encounter death and, ultimately, depersonalize it. So far, so good -- and some readers may ask, what else is new? In response, and speaking as a physician once hunkered down in those same lonely trenches, let me add a confession. While reading Chen’s early chapters, my heart leapt more than once as decades-old memories flooded back, heavy with buried emotion.

Take, for example, the hyper-visceral experience of the anatomy lab, redolent with formaldehyde-infused cadavers. One of Chen’s passages recounts the day when she and three lab partners were supposed to divide their female cadaver’s pelvis. Despite the author’s budding fascination with human anatomy, she could not wield the electric saw whose blade would cleave the pubis down to the buttocks, leaving “the legs turning outward like those of a dancer in the first position.” Instead, a more resolute colleague performed the deed, after which, Chen recalls, their lab mate fell mute for the rest of the afternoon.

A week or two later, the dissecting team learned the cause of their cadaver’s demise. Ugly, hardened deposits studded what should have been silky intestines, peritoneum and pelvic organs. Not “benign” old age, but advanced ovarian cancer had stolen the life of the woman who had bequeathed her remains for the erudition of future doctors.

Other equally intense, archetypal episodes -- the memento mori, if you will, of all modern medical trainees -- quickly follow. The first “pronouncing” of a hospital patient’s death. The first full-bore “Code Blue” as witnessed through the dilated pupils of a third-year clinical clerk. The first protracted death of an intensive care unit denizen whose day-in, day-out pre-mortem monitoring had been assigned to Chen. (She was carefully supervised, needless to say, by a small army of more experienced mentors.) The multi-year metamorphosis into seasoned physician had begun and, along with it, Chen reveals, a tendency learned from teachers and colleagues “to suspend or suppress any shared human feelings for my dying patients, as if doing so would make me a better doctor.”

Following her general surgery residency at Yale University, Chen completed her training at the National Cancer Institute and finally at UCLA, where her work as a junior transplant surgeon earned her UCLA’s 1999 Outstanding Physician of the Year award. Chen often harvested organs from brain-dead donors in one hospital, then helped to transport and implant them in recipients hovering near death at UCLA.

One cannot help but wonder if the daily juxtaposition of life and death on the liver transplant unit was not only the final, grueling chapter of her medical apprenticeship, but a turning point that made her decide to write this book as well. Although transplantation medicine is decidedly heroic, it also immerses doctors and nurses in the care of very sick people -- some still sentient, others in utter twilight, their lives chronically dependent on care and ever vulnerable to fresh disaster. How could anyone tend children (whom Chen describes as “[o]ften comatose ... in beds meant for adults, hemmed in by a bevy of machines that whirr, whistle, and beep over their every movement, mechanical nannies who cannot stop clucking” ) in such a state without some emotional shutdown?

But this is a minor cavil. Few insiders, I believe, would argue with Chen’s basic premise: that stunning advances in medicine and a strong mission to prevail and “cure” have also wrought psychological disconnection from medicine’s inevitable failures -- especially in teaching hospitals often manned by doctors who have not yet felt death’s icy breath in their own lives.

As Chen so eloquently argues, a zeal to cure is no excuse for failing to communicate prognoses honestly or for sidestepping ongoing dialogue with patients and families as medical events deteriorate. Any book that calls a spade a spade on these touchy topics deserves high kudos for candor and compassion. In particular, I commend “Final Exam” to every medical student and young physician.

Having said that, the flip side of the equation is shown by my brother-in-law’s example. From the outset, he never shirked from researching his disease or asking explicit questions of his doctors. He also experienced his dying as a richly human and emotional process -- filled with personal connection as opposed to a single-minded focus on increasingly fruitless treatments.

It may seem paradoxical, but as life expectancy increases in privileged societies, a mature awareness and engagement with death is incumbent on us all. The alternate scenario -- large-scale warehousing of end-of-life disasters in lieu of wiser societal investments in health -- is no longer mere medical sci-fi. *