Final Exam, by Pauline Chen

Doctors' dilemmas in the face of death
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The Independent Culture

I was counting up, recently, the number of people close to me whom I've seen in the final stages of dying – or even, actually dying in a couple of cases – and was astonished to find it as many as seven. It's no accident. I find death interesting, and I'm drawn to it. So, for me, Pauline Chen's beautifully-written Final Exam: a surgeon's reflections on mortality was fascinating because she, also, is rivetted by death.

Chen is a US surgeon specialising in liver and kidney transplants, so she has seen hundreds of deaths – the majority come from her work "harvesting" bits from live bodies.

Her premise is that too many doctors are obsessed with avoiding death; and that they use far too many invasive techniques, like mechanical ventilation, CPR, dialysis, artificial nutrition and hydration, when they should be helping the patient to die as comfortably as possible.

In a recent US study, it was found that a lot of damage and unnecessary pain is inflicted by over-treating. One third of fully trained physicians believed that they had acted against their conscience in providing care to the terminally ill. They find it very hard to accept the transition from "living with" to "dying from".

Indeed, there is a theory that doctors are worse than most people at facing death. As Sherland Nuland writes in his book How we Die, "of all the professions, medicine is one of the most likely to attract people with high personal anxieties about dying. We become doctors because our ability to cure gives us power over the death of which we are so afraid." This deeply rooted angst about death thus "replicates itself over and over again like some tragic hereditary disease," writes Chen.

"Even in deciding to do nothing," she writes, "we imbue these periods with action. It is as if we are dynamically managing time, and at the end of that time there may be more treatment for us to initiate."

Even worse, a quarter of oncologists actually failed to tell their patients that they had incurable cancer. Not one of us in our right minds wants our doctors to become so emotionally involved that their eyes are clouding with tears and their hands trembling with compassionate anxiety as they remove our tumours or stitch up bits that have come adrift. But nor do we want their professional detachment, no doubt born of fear, to blind them to the fact that when the time comes, we would prefer compassion and morphine to painful mechanical aids that keep us alive at all costs.

At the end, rather than simply looking for the signs of death in an apparent corpse – the "Q" sign of an open mouth with the tongue sticking out, no heartbeats or breaths, and no response to painful stimuli – Chen has now learnt true compassion. She looks around for members of the family she might be able to comfort, with explanations, embraces and reassurances that everything was done to make the patient too feel comfortable at the end.

Virginia Ironside's novel 'No! I Don't Want to Join a Bookclub' is published by Penguin

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