Advance planning should be a public health issue

“Medical training rarely deals with helping the dying patient find peace and comfort. In fact, most physicians are uncomfortable with the entire subject. I believe it is one of the most neglected aspects of medical care. I have spent my career as a pulmonary and critical care physician, and I have cared for thousands of dying patients. In many cases, both the patients and I knew that they were dying. After I provided clinical and supportive care, I would walk away from their bedside and go on with my work and go home to my family. Now the world has turned around for me. I have widespread metastatic disease to my lungs and bones.”

This was written by the prominent physician educator Roger Bone as he was dying and exploring the classical literature about death and dying. In Bone’s extensive search of classical literature he found little to explain death itself. “In summary, the great classics, the most significant works in literary history, have had a seminal effect on the behavior and attitudes of our world today, concerning themselves as they do with the issues of love, tragedy, seduction, pride, intrigue, suspense, murder, vanity, fantasy, evil, cruelty, greed, adultery, deceit, depression, fear, brutality, hypocrisy, pride, chivalry, heroism, romance, honor, loyalty, and friendship. But only rarely do they deal with an understanding of death. Notable exceptions include the passages visited above, most memorable in the scene of Beth’s death in Little Women, Emily’s death in Our Town, and Thoreau’s observations in Walden. I examined the classics closely for answers and was left with the conclusion that if you have limited time, read Thoreau, Alcott, and Wilder.”

Perhaps we can get a glimpse about the “D” word from authors. “Dying is a very dull, dreary affair. And my advice to you is to have nothing whatever to do with it.” (Somerset Maughan) Perhaps the denial that we all have is healthy to some degree, but ultimately harmful when we have to face and plan for the inevitable.

“It’s not that I’m afraid to die, I just don’t want to be there when it happens.” (Woody Allen) The point here is that we really do have some fear, and that denial can be humorous as long as we’re not facing a real crisis.

“Life is pleasant. Death is peaceful. It’s the transition that’s troublesome.” (Isaac Asimov) I often heard this from patients, “It’s the dying I’m afraid of!”

Advance planning is something we, as a society, don’t do well. Most of us tend not to save adequately for retirement, don’t execute wills, and don’t complete advance directives. Appropriately we tend to live in the present, “the now”. So how do we deal with educating ourselves, our leaders, and our governments to balance “the now” with “the future”. Ultimately the education about advance planning needs to come from the heath professions, medical societies, communities, states, and the federal government. Viewing this as a public health issue with the rapid aging of the population, the CDC has created a program to educate heath professionals.

None of this, of course, really addresses the mystery of what follows death. Roger Bone found his comfort in the Bible, Helen Keller in Swedenborg’s writings in Heaven and Hell, but the journey remains ours alone, hopefully with our creator gently carrying us.

Jim deMaine is a pulmonary physician who blogs at End of Life – thoughts from an MD.

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