End of Life University

The old man and the young woman sat across from one another stiffly perched on plastic chairs, staring down at the floor – doctor and patient. The tension in the room, exaggerated by the silence between them, was almost unbearable. Then the patient, stroking a trembling, emaciated hand across a hairless scalp, spoke haltingly, “Doctor, promise me I’m not going to die.”

According to a recent post in the New York Times by columnist Jane Brody, this type of interaction with a terminally ill patient creates occupational distress for many doctors who are not equipped emotionally to handle such a difficult situation. She states that doctors who are unable to cope with “their own feelings of frustration, failure and helplessness … may react with anger, abruptness and avoidance” toward their patients who are dying. When this occurs doctors may recommend futile treatments to patients at the end of life because they cannot connect with those patients on a human, suffering level and have nothing else to offer them.

The article touts mindfulness meditation, a practice recommended by palliative care specialist Dr. Michael Kearney, as a solution for discontent and disconnected doctors. I wholeheartedly agree that mindfulness meditation can be a very helpful practice for calming anxiety and learning to be present. However, I believe that this problem—doctors who find themselves unable to cope with perceived failure when a patient is dying—requires a deeper and more fundamental solution: doctors need a new understanding of death and therefore, life. 

These are the fundamental truths of death and dying that should be taught to every medical student from the first day of training:

1. Death is inevitable.

Every living thing on Earth will die. Death ultimately cannot be avoided or prevented, even though it can and should be forestalled when reasonably possible. The fact that every patient eventually dies creates a sense of hopelessness and futility for doctors if they pit themselves against death as an enemy—for that is a battle that can never be won. But those who recognize that the end of life is actually the final stage of human development can help their patients face their last days with dignity and make reasonable choices for their care and treatment.

2. Death is a mystery.

No matter how hard we try we simply cannot control or accurately predict when natural death will occur. In my hospice work I have seen many patients who lived far longer than expected, against all reasonable odds; and I have also seen patients who died much sooner than expected, from causes not related to their terminal illness. We have to accept this mysterious nature of death even while we work to circumvent it or prepare for its arrival.

3. Death makes life more precious.

When life is perceived against the dark backdrop of death, we can see how it shines and glistens for us, ever more precious because it is fleeting. This is the gift that our mortal nature provides us—an opportunity to cherish each moment simply for the fact that it will not last. 

4. Dying provides an opportunity for transformation.

In my work with hospice patients I have witnessed over and over the transformative power of love and forgiveness during the last days of life. When dying is respected as a natural part of life and time is allowed for the process to unfold, patients can turn their focus to matters of the heart and soul and find meaning in both life and death. But this does not happen when death is perceived as an enemy that must be resisted until the final breath is taken. Doctors can help their patients change focus by advising them with honesty when the time comes that pursuing further treatment is futile and will cause more harm than benefit.

 In my ideal world doctors would be educated in the wisdom of all aspects of health, including the decline of physical health that ends in death. Doctors would be the guides who help us make reasonable choices, who see beyond our fears, and who possess the compassion and tools to ease our suffering.  Doctors then would be the wisest members of our society, never deluded by the myth of immortality.

When a doctor such as this is asked by a patient, “How can I live, knowing I am going to die?’ the answer would be:

“You must turn your focus to those things that matter the most to you. Put your energy into living each and every moment fully rather than trying to escape death. Then when the time of your death arrives—and no one really knows when that time will be—you won’t feel bitter and deprived. You will be filled with the joy of a life of meaning—no matter how many years of life you have been given.”

Healing takes place, not when death is forestalled, but when life is embraced and affirmed in its entirety, from beginning to end. When doctors can fully understand the nature of death and dying they will become the true healers that are desperately needed in this world.