Some musings

‘Death doesn’t discriminate

Between the sinners and the saints

It takes and it takes and it takes.’

Lin-Manuel Miranda from ‘Hamilton’

‘Today, tomorrow, and yesterday too

The flowers are dyin’, as all things do’

Bob Dylan: ‘I contain multitudes’

Last summer we spent our holiday in Northern Spain. It was my first time in the country and I thoroughly enjoyed my time there, walking in the Los Picos de Europa, swimming off the north coast, and sampling the local fare. One thing though would have improved the experience – if I had bothered to learn a little of the language. It’s remarkable how isolated and uneasy one can feel performing the most simple of activities when you neither understand or are understood by the people with whom you are interacting.

The same can be said for that place that doctors inhabit for large periods of their lives – the land of medicine. I wonder how our patients feel when they consult with us and we fail to speak in their natural tongue. Does our language leave them feeling isolated and uneasy too?

But this post isn’t about the rather obvious importance of being careful that we don’t slip into speaking a form of ‘medicalese’ that is incomprehensible to our patients. Rather, it is about our need to lean the language of growing old and dying.

It’s important that we do so for at least three reasons.

Firstly many of our patients already live in the place where such language needs to be spoken, but too often isn’t. We are frequently like the Englishman abroad who, by speaking a little louder and a little more slowly, foolishly imagines that he will make himself understood. We do this by labelling people with conditions rather than treating them as individuals, by exaggerating the benefits of interventions that have long since past their point of usefulness and by insisting on the absolute importance of our treatments, be they statins or chemotherapy. Such talk can encourage patients to continue to unreasonably hope in that which medicine too often falsely promises and thus inhibit, not only the appropriate expression of grief, but the search for hope elsewhere.

A little honesty as to the inevitability of death would not only be more candid. but also, paradoxically perhaps, more helpful. When you know you’re dying, having your doctor with you in that experience will be less isolating than having to listen to someone who refuses to face facts and keeps talking about what should be tried next. Far from being reassuring, such talk urging patients to keep fighting only serves to heighten their unease and prevents them from easing themselves gently towards their death.

Secondly, such honesty may also help doctors too – to lessen their feelings of guilt when the inevitable happens. Too often, in an attempt to preserve our status, the death of a patient can lead us on a search for something or someone other than ourselves to blame for what has happened. An honest acceptance of the inevitability of death will free us from this self serving practice that sadly I sometimes see, at least in myself. Lose our exaggerated belief in ourselves and we may find that we are better able to support those who grieve over a far greater loss.

Though it is commonplace in our speech to say how our treatments save lives, the reality is that no doctor, nurse or other health care professional ever saved a life – at best we only ever prolong some. Of course this is often a wonderfully worthwhile thing to do – but it isn’t always. We need to realise there is a difference between things that can be prevented and things that can’t. There comes a point when our efforts to extend life need to come to an end and we need to start speaking the same language that our patients, all too aware of what is happening to them, have already begun to speak. We need to talk about death. Our vocabulary needs to expand so as to be able to talk about the sadness of loss, the pain of a life coming to an end and the inevitable regret of things that might have been which, now, can never be.

The third reason we need to learn to speak about growing old and dying is that it is the language of the land in which we all will one day make our home. Conjugating the verb ‘to grow old and die’ gives us both the first person singular as well as the third person plural. I suspect the language may be a hard one to pick up so, though I’m only 53, perhaps I should start learning it now.

So why the melancholic introspection on holiday? Simply because, whilst away, I had been reading Alan Bennett’s beautifully written ‘Untold Stories’. In it he chronicles the illnesses of family members and the effect they have on others. He also describes the death of a number of his relatives including that of his mother. ‘All her life’, he writes of her as she dies, ‘she had hoped to pass unnoticed and now she does’. The book helpfully speaks to the ordinariness, perhaps even banality, of much of life and death and it is, ultimately, an uplifting and enlightening read One short paragraph that particularly caught my eye reads like this:

‘A diagnosis, which is, essentially, a naming, puts someone in a category. Neither Mam nor Dad was ever a big joiner, ‘not being able to mix’ both their affliction and their boast. So now, faced with the choice of enrolling her in the ranks of those diagnosed and named as having Alzheimer’s, I still prefer to keep my mother separate, so that she can die as she has lived, keeping herself to herself’

I hope, when my time comes, rather than being treated as a condition to be managed and offered futile hopes of a cure, I am seen as a person whose life is drawing to a close, spoken to as an individual cognisant of my impending death and given the time and space to get on with the important matter of dying well. Until then I hope I can offer that same courtesy and respect to those whose last days I am privileged, as their doctor, to be a part.

Dying can’t be easy, but it must surely help if we use words that allow us to acknowledge its reality and face it together rather than words which seek to pretend it isn’t really happening and serve only to leave the one dying to face it silently and alone.

We would all do well to remember that, ‘For everything there is a season, and a tine for every matter under heaven: a time to be born, and a time to die’ [Ecclesiastes 3:1-2].