End-Of-Life Literature

In an interview about his new book, Being Mortal: Medicine and What Matters in the End, the surgeon and writer Atul Gawande runs down the literary influences that inform his approach to medicine:

What books most influenced your decision to become a doctor, and your approach to medicine? Who are your favorite physician-writers?

I have so many: Anton Chekhov, Sir Arthur Conan Doyle, John Keats, Walker Percy. Mikhail Bulgakov was famous for “The Master and Margarita,” but his “Country Doctor’s Notebook” is fascinating, too. So is William Carlos Williams’s “Doctor Stories.” When I was in medical school, a trio of doctors who’d come out with nonfiction books around that time awoke me to the concrete, practical idea that one could be both a physician and attempt to write seriously: Oliver Sacks, Sherwin Nuland and Abraham Verghese. I reread Lewis Thomas constantly. Richard Selzer’s essays on his life as a surgeon — for instance, “Mortal Lessons,” “Confessions of a Knife” and “Letters to a Young Doctor” — can seem overwritten, but they have stayed with me for years now. These writers all transcend the term “physician-writers.” They’re just writers, telling us about the experience of being human.

What book would you most recommend to an aspiring doctor today?

Tolstoy’s “The Death of Ivan Ilyich.” It’s the best portrayal of sickness and suffering I have ever read — minutely observed, difficult and still true a century and a quarter later.

Great writing on illness and mortality extends vastly beyond works by doctors, and I can’t let the opportunity go without mentioning at least a few more of my non-doctor favorites: There’s Anatole Broyard’s amazing memoir of his own dying, “Intoxicated by My Illness,” Anne Fadiman’s “The Spirit Catches You and You Fall Down” and Joan Didion’s “The Year of Magical Thinking.” Oh, and Sylvia Plath’s “The Bell Jar,” Ken Kesey’s “One Flew Over the Cuckoo’s Nest” and William Styron’s “Darkness Visible.” And I can’t leave out Thomas Mann’s “The Magic Mountain” or Virginia Woolf’s “On Being Ill.” These all deserve readers of any kind. But about one in five of us work in health care in some way, and we have a particular responsibility to understand what people experience when their body or mind fails them. Our textbooks and manuals aren’t enough for that task.

Gavin Francis notes how Gawande’s personal story informs his perspective on end of life care:

Towards the end of the book, he tells the story of his own father’s decline and death from a tumour of the spine. His experience as a surgeon melts away and he finds himself navigating infirmity and dependency as a son, rather than as a clinician. It’s the worried son, not the Boston surgeon, who reflects on the qualities he values in the doctors treating his father: not bullish arrogance, but acknowledgement of uncertainties and a willingness to accept risks. He finds doctors communicate most effectively when they jettison the position of detached, clinical observers and talk in terms of how they feel: “I am worried about your tumour because … ” Often the bravest and most humane decision, he realises, is to do nothing at all.

When time becomes short, Gawande has the presence of mind to ask his father: “How much are you willing to go through just to have a chance of living longer?” The answer helps guide his father to a relatively peaceful death in the arms of his family, as opposed to a technologised end on an intensive care unit. The message resounding through Being Mortal is that our lives have narrative – we all want to be the authors of our own stories, and in stories endings matter. Doctors and other clinicians have to get better at helping people with their endings, otherwise more and more of us will end our lives babbling behind shining doors.

Recent Dish on end-of-life concerns here, here, and here.