Is there such thing as a better death? This is the question posed by Australian oncologist and award-winning author Ranjana Srivastava in a fascinating article reproduced here
This is an edited version of an article that first appeared in The Guardian.
It isn’t until my patient dies that I calculate we have known each other for 10 years, the time it took for her recurrent cancer to extinguish her life. I use the word ‘extinguish’ deliberately, for her two young children should have had her for longer. Her devoted husband sends me a peaceful photo of her from the hospice and details of her funeral. I choke – and tell myself that I have a full clinic of patients.
Sometime later, I call him.
“I am sorry she’s gone. How are you?”
“To be honest, relieved.” His voice sounds definite and strong.
Why didn’t we recognise the warning signs? I wish I had an answer for my dead patient’s husband
The response takes me completely by surprise, evoking a curious mix of admiration and resistance. I think I was expecting to hear he is devastated; that after a thousand appointments, his days have fallen quiet; that he can’t get over questions about the randomness of life. I know him well enough to ask about the children. I never met them but they were always part of my equation of keeping her well for as long as possible.
“They’re back at school, doing OK. They’ve expected this for a long time.”
In that moment, I know that they’ll be all right. As her health alarmingly deteriorated, I’d worried about its ultimate effect on him. What happens to survivors consumed by a loved one’s illness? What moves in to fill the void? In this instance, a deep sense of peace and closure.
Though her death was inevitable, many of us had shed tears. After a decade of shared lives, I realise this is our final conversation and now I want to relay our sorrow without somehow diminishing his sense of relief.
“I want you to know how much we admired her strength and your devotion to her. You did everything you could.”
My voice cracks. He thanks me softly and we hang up.
An ancient truth
The next minute I am hurrying up the stairs to rescue my perturbed resident from an irate patient. He’s in his 80s and the situation is best summed up by the resident. “He can’t believe he is dying and his family isn’t helping, either.”
I reach the bedside of the angry patient and disbelieving relatives seeking to re-prosecute the case of his progressive cancer and my ‘failure’ to find a viable treatment. I draw pictures, share results and patiently explain how further chemotherapy is dangerous and why it’s inappropriate, even unethical, to enrol him in a clinical trial in his bed-bound condition. But I can also see my words falling on deaf ears, which means that the end-of-life care he needs isn’t going to eventuate.
Desperately, I ask, “What would you like me to do?”
“To make me better, obviously.”
The palliative care nurse sighs. I am reminded of a saying from the Mahabharata, a 3,000-year-old Indian epic.
“What is the most surprising thing in the world?” a celestial figure asks a nobleman.
The nobleman replies, “Day after day, man sees countless people die but still he acts and thinks as if he will live forever.”
A better death
Being an oncologist is to have a window into how people from different walks of life contemplate their mortality – but in a society that struggles to view any death as ‘good’, it is also an unmistakeable opportunity to share what at least constitutes a better death.
Acceptance is foremost. Some of my most remarkable patients have accepted early that they have not been singled out by misfortune, that suffering, in different shapes, is the course of humanity. I once told a terminally ill patient how much I regretted her predicament. “But we all die. My time came a bit earlier and it’s nobody’s fault,” she replied with an equanimity that became the hallmark of her short life. She showed me how this vital understanding insulates us from excessive bitterness and rage while leaving open the possibility of doing everything we can to remain well and live a life of meaning.
The elements of a meaningful life may sound like a topic fit for armchair philosophers rather than the majority of us who have a hard enough time fitting in work, bills and care-giving duties. However, I routinely see how ‘ordinary’ people create meaning by deliberately practising forgiveness, kindness and generosity. I’ve often thought that the chemotherapy unit is one of the kindest places in the hospital; here, patients find the energy to bring lovingly baked scones and handmade cards to say thanks, and give encouragement, even though we all know the system periodically fails them. Others bear with delayed procedures, unexpectedly generous and genuine in their concern for patients who are even sicker.
Among their own substantial worries, I am always touched by how many patients ask after my children or care for my wellbeing. These simple and inexpensive gestures leave a legacy of goodwill for takers, but they also enrich the giver.
Family and friends – a crucial role
Modern life is governed by an individualistic philosophy but, when it comes to dying well, the role of family and friends is crucial. Illness – and with it the decline of our former proud and independent selves – can be ably tempered by loved ones who value us outside of our visible success and career accomplishments. When we feel diminished, they are best placed to reassure us that we are more than a title or a salary.
No-one can replace the family as the most potent reminder to the dying that their memory will be safe and cherished, and that it’s OK to let go. I see many people wanting to help their loved one achieve a better death but not knowing how. Those who succeed say that a key step is self-awareness. A reluctance to contemplate one’s own mortality makes it doubly hard to accompany others on the journey, and we would all do well to occasionally pause and reflect on the things that really matter.
Part of my job is to encounter surviving relatives in all kinds of places – at the pool, while buying groceries and in the clinic, when another family member is diagnosed with cancer. When I was younger, I used to wonder how anyone ever got over loss but the older I get the more I discover the infinite capacity of the human spirit to rise again.
A collective wisdom
Survivors grieve in all kinds of ways. One family brings a monthly picnic to grandpa’s grave, another scatters the ashes in the Ganges or the Atlantic, and another will need a lot more time. But I am consoled to find that reconciling to a death is possible without diminishing a person’s significance, something even the most heartbroken of us would do well to remember.
No individual could possibly have all the wisdom needed to live well and die peacefully, but to be an oncologist is to be granted access to the collective wisdom of patients. Many of my patients told their story because they wanted others to learn. They knew that they were dying but they would be thrilled if their lives provided a meaningful template for the rest of us trying to make sense of life and death.
Ranjana Srivastava is an Australian oncologist, award-winning author and Fulbright scholar. Her latest book is called A Better Death.