On Writing An Obituary

Richard Smith is an emeritus editor-on-chief of the British Medical Journal.  Just about everything he writes is prescient.  A recent piece of his in the BMJ deals with obituaries.  What would you like your obituary to contain?

“Just as I think everybody should have a living will, a plan for their funeral, and clear instructions on whether you want to be buried or cremated, so I advise thinking about your obituary or even obituaries…You might write it yourself, but many publications are sniffy about self-written obituaries. So you might do better to get somebody to write one for you, and that’s why Sir Anthony Grabham rang.  We worked well together and liked each other, although we were very different: him being a polished master of the establishment, whereas I’m a 'loose cannon,' to put it mildly"

Richard Smith: Writing an Obituary of the Living

The Conversation

A Revolutionary Plan for End-Of-Life Care

From Amazon:
There is an unspoken dark side of American medicine - keeping patients alive at any price. Two thirds of Americans die in healthcare institutions tethered to machines and tubes at bankrupting costs, even though research shows that most prefer to die at home in comfort, surrounded by loved ones.
Dr. Angelo E. Volandes believes that a life well lived deserves a good ending. Through the stories of seven patients and seven very different end-of-life experiences, he demonstrates that what people with a serious illness, who are approaching the end of their lives, need most is not new technologies but one simple thing: The Conversation. In this book, he argues for a radical re-envisioning of the patient-doctor relationship and offers ways for patients and their families to talk about this difficult issue to ensure that patients will be at the center and in charge of their medical care. 

This is a low book that the covers many aspects of end–of-life care. It will be useful to anyone who takes the time to read it. It compliments Gawande's Being Mortal. The Conversation is mostly directed to patients. Physicians may find it too simplistic, but it is still helpful in pointing out the discussions we should have with patients.

Volandes and his group have produced "The Conversation" videos which can be shown to patients to help with making end-of-life decisions. These videos are available at many institutions around the country. They would be helpful to have in an office setting, in addition. They can be shown on an iPad for convenience and portability. DJE
 

Oliver Sacks' Letter to the World

On February 19, 2015, Oliver Sacks had an Op-Ed piece in the New York Times about his diagnosis of terminal cancer: My Own Life.

I cannot pretend I am without fear. But my predominant feeling is one of gratitude. I have loved and been loved; I have been given much and I have given something in return; I have read and traveled and thought and written. I have had an intercourse with the world, the special intercourse of writers and readers.

Above all, I have been a sentient being, a thinking animal, on this beautiful planet, and that in itself has been an enormous privilege and adventure.

In this letter to the world he continues to teach us in his living and his dying.

Complicated Grief

Jane Brody's Personal Health column in the February 17th, 2015 NY Times is an informative and comprehensive discussion of "complicated grief."

Image from Times article

“Complicated grief is like a wound that doesn’t heal and can follow the loss of any close relationship. The risk of complicated grief is greatest — 10 percent to 20 percent — among those who lose a romantic partner and even higher among those who lose a child. It is more common following a sudden or violent death and most common among women older than 60, she reported."

See:  Brody: "When Grief Won't Relent"

Also referenced:

1) Shear MK. Clinical practice. Complicated grief. N Engl J Med. 2015 Jan 8;372(2):153-60.

2) The Center for Complicated Grief (Columbia University, NY)

Advanced Directives - NEJM Discussion

End Of Life Advanced Directive Discussion

New England Journal of Medicine, February 12, 2015, vol:372:pages:667-670

PDF of NEJM article.

Who should have the difficult discussion of the goals of care for a terminal patient? With whom does this responsibility lie? What course of action should be taken?

1. As the primary care physician, discuss the goals of care with the patient yourself.

2. Recommend that the oncology team discuss the goals of care with the patient.

3. Refer the patient to a palliative care physician who will discuss the goals of care with the patient.

To aid in your decision-making each of these approaches is defended in a short essay by an expert in the field.

N.B.  This is a an instructive article that will help patients and their care-givers.

The most useful comments came from palliative care physician, Diane Meier:  In an ideal world, every clinician caring for terminal patients would have the training and the team support to care for their patients throughout the course of their illness, especially during its most difficult and challenging phases.  Most primary care clinicians and specialists don't have time to manage complex symptoms, as well as emotional, practical, spiritual, and family needs, amid the escalating productivity requirements characterizing medical practice in the United States.  Most terminal patients’ care will be improved through access to specialist-level palliative care.

YOLO*

*  For those who are not Gen-Y members (aka Millennials), YOLO means "you only live once." 

Death Has a Sound

Death is the deepest of silence.
It is a quiet unlike any other.
Do you hear that?
Be still and listen.
There it is.
A quiet unlike any other.

Marla Lukofsky

Dec. 2006