Discussion Post for THE LOST ART OF DYING, Chapter 1, Pages 1-17

In this post, I will quote passages in Dr. Dugdale’s text that I find especially discussion worthy, pose questions about those passages, and share some of my thoughts. I invite you to reply in the “comment” box below, responding to what I or others have posted, or to any part of Dr. Dugdale’s book that we have read together this week.

More than 50 people signed up to participate in this group reading. I hope all of us will benefit and contribute to our discussions. To that end, I ask you to please be judicious, concise, on topic, and respectful in your comments. In our common pursuit of wisdom about human death and dying, let’s remember that we are considering a difficult, sensitive, and deeply personal subject.

So here we go . . .

I regret that we resuscitated Mr. W. J. Turner.

Page 1

In this first sentence of her book, I suppose Dr. Dugdale to be expressing a general regret for the resuscitation that she will go on to describe. But that general regret might include specific regrets. Does she regret her own actions? Does she regret the decision of Mr. Turner’s daughters? Does she regret the way in which Mr. Turner’s condition was explained to them?

Dr. Dugdale says on page 5 that it “felt like a personal and professional failure” and that she and her colleagues “contributed to [Mr. Turner’s] dying poorly.” It does not seem to me that she thinks she should have done differently or that she is rebuking herself for a violation of conscience. It does not seem that her regret is about individual blame, whether of herself, Mr. Turner’s daughters, or any of the other medical professionals involved. I think Dr. Dugdale’s regret is more about the system of which she is a part and the culture to which she belongs, and the way both contributed to Mr. Turner dying the way he did.

His daughters assured the medical team that he would ‘beat this cancer.’

Page 1

I find the use of combat language to talk about disease frequent and generally unhelpful. We talk about “bouts” with cancer, winning (or losing) the “fight” with this or that disease, etc. Dr. Dugdale doesn’t say much about this in the pages we are considering, so I won’t say much either. But I do think it’s an aspect of our culture’s approach to sickness and death that is noteworthy. I expect we will return to this again in our reading of this book.

This has always seemed to me as something of a paradox. It seems curious that the people who believe most fervently in divine healing also cling most doggedly to the technology of mortals.

Page 6

Is this paradox that Dr. Dugdale articulates in reference to Christians a true paradox or a false paradox? By that I mean, is she pointing to two authentic Christian beliefs (or expressions of Christian belief) that seem to contradict but actually do not? Or is she pointing to beliefs and practices that really are contradictory or inconsistent?

I think anything like a complete answer to that question would have to be lengthy and complex and is therefore beyond our scope. But a couple thoughts might be worthwhile.

First, I think the paradox Dr. Dugdale finds curious is part of a larger Christian paradox that is true. Christians believe in God’s promise of a new, better, eternal life after death, which they express by their hopeful (even joyful) acceptance of death. Christians also believe that mortal life is a sacred gift from God, which they express by their commitment to preserve, protect, and care for every human life regardless of its stage of development or perceived quality. Those convictions can seem contradictory. How can we hold mortal life sacred, while hoping and praying for the immortal life to come? How should we (sometimes doggedly) seek to preserve our lives on earth, while joyfully welcoming the life that follows death? Those are challenging questions that raise lots of other questions. I think, however, that they arise from authentic Christian beliefs and authentically articulate the challenge of Christian life and death. For that reason, I would call this a true Christian paradox.

Second, The paradox that Dr. Dugdale finds curious seems not to be the one we just considered, between preserving mortal life and welcoming God’s gift of immortal life. It seems rather to be between preserving mortal life (technologically) and welcoming God’s gift of healing in this mortal life. The consideration of eternal life seems absent. A couple thoughts about this: (1) From a moral perspective, technology does not automatically make life-sustaining measures optional. Just because a treatment or way of providing care didn’t exist in the past, doesn’t mean we aren’t bound to use the life-sustaining measures that are now available to us. (2) We don’t need to buy God time. God can work wonders in any way and at any time (think of Martha’s words to Jesus after Lazarus had been in the tomb four days: “Even now I know that anything you ask of God, God will give you”). If the paradox Dr. Dugdale describes presumes the belief that God might need us to buy time to enable a miracle, it is certainly a false Christian paradox.

It’s no wonder that some patients, not excepting Mr. Turner and his family, regard with suspicion the seeming eagerness of physicians to withhold chest compressions or remove life support.

Page 10

Dr. Dugdale gives examples of exploitative experimentation from the recent past that support the above remark. She is surely right that the kinds of incidents she relates make suspicion of doctors understandable. But would it be reasonable to be suspicious about doctors’ intentions with respect to end-of-life care based on exploitative experiments from 50 or more years ago? Are there other reasons to be suspicious about doctors’ intentions in end-of-life care? Are there good reasons related to organ donation? financial efficiency? ethical disagreements about necessary forms of care? faith-based concerns or priorities?

No movement. No sound. Total stillness.

Page 12

Dr. Dugdale recalls the moments after Mr. Turner’s last resuscitation attempt failed and he was declared dead. She then relates how she and the other doctors “left [Mr. Turner’s daughters] with the chaplain and social worker.” When the flurry of activity turns into the solitude of grief and the doctors have gone away, what do you do in that silence?”

This morning (October 5), I prayed with the adult children of an elderly man who had just died in his hospital bed. After our prayer, we remained in silence for some time. It was a peaceful silence. A notable contrast, I think, to the silence Dr. Dugdale describes.

Mr. Turner’s story illustrates the ways that we–as individuals and as a society–fail to die well.

Page 13

What it means to die well is the question we will be exploring with Dr. Dugdale through our reading of this book. But how does Mr. Turner’s story illustrate that? Is it the unseemliness of his final night? The futility of the resuscitation attempts? The attitude of his family? The dysfunction of hospital protocols requiring his multiple codes? How else?

Is life extension always the goal of health care? . . . Is it wise to act as if death is avoidable and thereby attempt to delay death indefinitely? . . . Where is the wisdom on dying wisely?

Pages 15 and 16

The first two questions seem somewhat rhetorical, presuming that the answer is No. But it may be instructive to consider why the answer is No or why the questions are being asked at all. The third question is one that Dr. Dugdale will give several answers to in the course of this book, beginning with her discovery of the ars moriendi, which we will discuss next week.

27 thoughts on “Discussion Post for THE LOST ART OF DYING, Chapter 1, Pages 1-17”

  1. The regret of the resuscitation is really a statement of empathy for Mr. Turner. The success of the Code Blue is only a procedural success and does not enhance his chances of survival or relieve any suffering. The conversations after the first code reveal the awareness that their success was futile. Would a refusal by Dr. Dugdale to participate in the codes been appropriate? No!! On page 2 “That’s me, Have to run. Back later.” implies that she was serving a rotation in the emergency room and was not incidentally seeing a known patient with asthma or had been consulted by an ER doctor for the college student in question. It is the ER doctor in many hospitals who is the leader of the code team while other hospitals have a dedicated code team. On page 4 she mentions being directed by the code team leader and on page 11 the code team leader stops the code. Dr. Dugdale was fulfilling her obligations to the code team and its leader and was not responsible for the decisions to resuscitate. The problem for Dr. Dugdale in this situation is the lack of personal satisfaction a doctor experiences when a patient has benefited from the doctor’s recommendations or efforts. There was no benefit for Mr. Turner in this case. Another problem is on of isolation of the patient which can occur in the hierarchy of a teaching hospital (page 3) or in a hospitalist dominanted system. In both of these situations, there is a constant turnover of treating personnel who have no prior relationship or knowledge of the patient until the patient appears on their admission list. In this case, it was the intern who ‘knew Mr. Turner best”. With COVID this isolation has worsened since the family is not allowed to sit with the patient. Was there any prior discussion with the patient or his family about his metastatic prostate cancer and the urologist, medical oncologist, or radiation oncologist? Probably so, but denial or childlike faith in miracles and the possibility of dementia at the age of 88 years resulted in no end of life documents or instructions. The silence is a void left by an unrealized miracle, failure to communicate and plan regarding his terminal status, and the unknown future of the family as a result of Mr. Turner’s death. I will confess at this point that I am a retired urologic surgeion. My policy early in these situations was to urge my patients while they were physically and mentally able to decide how they wanted to spend their time, to think about their legacy, to prepare the appropriate legal work, to reflect with gratitude for their life and to find peace ( My soul waits in silence on God alone, from Him comes my salvation. Psalms 62:1) in accepting their mortality. In regards to the Christian Paradox, it is a comparison between the known (mortal life) and the promise of eternal life. Often the eternal life is described in physical terms as in chapter 21 of Revelations. A better explanation is found in John 17:3 where we ” know the only true God and Jesus Christ.” It is the difference between believe and trust. A rope may have a designated tensile strength of 300 lbs. according to a testing lab. This we may accept and believe, but trust occurs when we climb or descend a mountain using that rope. In approaching death we may try to postpone our demise until trust replaces our belief.

  2. The “we” who resusitated Mr. Turner several times seems to refer to the entire “medical machine & industry”….in all its forms…The paradox seems to be our “value life ..above all”.,as my elderly mom with all her faculties chose open heart some 20 yrs.ago.. and then a few years ago,I recall a doctor commenting to me over the telephone from across the country..concerning my aging uncle for whom I was the remaining relative…”just because the technology is available, does not mean it has to be used” (this was after an intrusive procedure) He remains in a facility today, unaware of his name or person….The exploitation and experimentation continues on,in many forms,…all as we, the “population” and “society” are “consumers”…products exist and we choose to “purchase” , or not, if we have the ability to “make the choice”…As for individuals dying well…I recall last year sharing singing & praying with my sister and then as days went on, reading bedside as her terminal illness ran its course…from a book of Catholic stories…skipping parts…waiting for her to “sleep”….or changing sentences as I scanned ahead if they seemed too unpleasant to be uttered aloud by me….her hand squeezing mine every so often…. as I reflect back, this was the best I could offer (in addition to oral prayers said with her and other family members before she could no longer reply(or sing) ……all while extraordinary/heroic means were being used…The delaying death indefinitely …or its being “avoidable” seems to echo back from some of the Health care proxy laws/forms and efforts by well meaning persons entrusted with this weighy responsibility to try to “do” (or “not to do” )what the person wanted/had wanted …soo unclear many times..soo unnecessary….and so”costly” as well…in terms of resources and emotions..

    1. Thanks, Vera. I think your suggestion that end-of-life treatments can be “emotionally costly” gets at an important aspect of what Dr. Dugdale means by “dying poorly.” Being emotionally invested in the success of desperate treatments could make it harder for patients and families to feel the love, peace, and hope that should predominate in the time before death.

  3. Reading Dr. Dugdale’s vignette brought back memories of working as an ICU nurse at an urban teaching hospital where I participated in “codes” like Mr. Turner’s. Regret, in situations like that, is common. It’s not because we regret eventually failing to bring a terminally ill person back to life. That happens. We know that death is a part of life. It’s because, deep down, we know we treated a vulnerable person in a way that we wouldn’t want to be treated or truly think is right. Our conscience hurts. No one I know wants a death like that. Those feelings are hard to discuss but they often involve guilt and shame and very quickly, get buried under a pile of excuses and rationalizations. Including the tendency to think that “erring on the safe side” and “doing everything possible” is the safest default position – especially if there’s a chance of getting into a dispute with the family or that you, or the hospital, could be sued for “failure to rescue” or worse.

    It’s good to be talking about death. Pretending that it’s not an issue won’t make it so.

  4. Dear all: I hope this is O.K. to post : I usually listen to anything created by “The Mindful Healthcare ” group as it often guides me and my work in hospitals(until Covid , I worked in NYC hospitals as an artist-in-residence ,primarily in cancer centers) but their work also guides me in life. Because my area in Queens NY has been I.D.ed as a Covid hotspot I have been distracted and have not listened to any of the presentations but am now catching up on the “Compassionate patient care” talk . As I listen, it occurs to me that this offering might be of interest to some of you ;here is the link and some of the presentations are still free to listen to.Take good care/enjoy & be well. Regina

  5. I think there is no one size fits all approach to living or dying. As a Christian, I do believe in miracles. I also have my suspicions about people. I do think that people feel that one person’s life is worth more than another person’s life. For some people the doctors gave the family a few more precious moments but for another it was more suffering. To whom, does that decision belong?

  6. As a physician, it is my responsibility to provide the best care possible to every patient and to inform him/her as best as I can. It is not my job to assure a “beautiful”death. It is my job to allow them to make an informed choice in order to decide the quality of life that they want for their remaining days. I will do my best to save them and I will always offer my assessment to help inform them. I never recommend when someone should die but just professional guidance/advice. Not sure how Catholic doctrine factors into this situation.
    Thank you.

  7. I think the paradox Dr D points out may be that although Christians believe God is capable of performing miracles during any point in a patients illness, at the time when medical interventions will no longer sustain life, people sometimes feel they must continue to fight for these interventions, even against medical advice, instead of placing their life in God’s hands.

  8. I agree. No matter what kind of language you use, putting the onus of the outcome of an illness on the patient just provides added stress. As Christians we realize that we are in God’s hands, we do the best we can, but He is in charge.

  9. Father, you say “But would it be reasonable to be suspicious about doctors’ intentions with respect to end-of-life care based on exploitative experiments from 50 or more years ago? Are there other reasons to be suspicious about doctors’ intentions in end-of-life care?”
    The feeling many African Americans have about medical care isn’t only based on the past. As a chaplain, I’ve asked Black patients how they are being treated while in the hospital, and once they see I’m receptive, they tell me the truth: Structural racism is alive and well in the medical system. For example, Black patients are routinely suspect if they ask for pain meds.; Black residents have told them they learned that Blacks feel less pain than whites in med school or during residency, etc. So it makes sense to me that Black families think the system is geared to saving white people instead of Black people, and that they are only given resources if they are assertive. I’m guessing that’s part of what happened with Mr. Turner’s family. Also, families are pressured to “do everything,” by relatives and friends to prove they love and value the patient–so there’s pressure from outsiders. When white doctors explain the cost (e.g. broken ribs, pain), they say they’re willing to risk it–but they may not believe the docs.

  10. Page 1. “..,none of us knew for certain whether his family understood the immensity of his disease…” Since hospitals have been taken over by major corporations, patients are no longer being taken cases of by their personal physicians who they and their family may have had a long term relationship with. Instead, they are cared for by hospitalists and residents who may be well trained in acute care, but who really do not know the patient. I think Dr D regrets she was forced to take part in the resuscitation of Mr. W without having a chance to really speak to the patient and his family with a multi disciplinary team to discuss and make sure the patient and family knew a resuscitation would not lead to a cure or delay for any length of time his ultimate death.

  11. P. 1: Modern medical treatment can be brutal, more painful than if the patient were left alone. The idea that we should “fight” cancer at all costs can lead us to forget quality of life, especially when the treatment, here resuscitation, has very little chance of efficacy. If we do not ask doctors to do everything possible, we feel guilty, as if the patient died because of us. But patient suffering should be considered too.

    On p. 6, the point Dugdale is making, I think, is that resuscitation for this patient was not “life-sustaining.” In fact, she suggests it may have hastened his death. Technology is a two-edged sword.

    On p. 10, many people think there is a “seeming eagerness of physicians to withhold” treatment.. I think this is partly because we have come to believe the hype about new treatments and medicines: “This will save you.” And we forget that death is inevitable. Doctors don’t discuss this inevitability enough with patients and their families. Sometimes we have to turn round and face the presence of death instead of pretending we can endlessly avoid it.

  12. I’m coming to this book from having an experience similar to the man’s family, albeit with different decisions made! My best friend (for whom I had healthcare power of attorney due to dementia) died almost exactly a year ago in hospice care, after 46 years of priesthood (18 as a bishop). I still very much question my decisions during his final three years–and even my prayers! For me, the paradox that was most difficult to reconcile at the end was the recognition that death is an enemy that came into the world with the Fall, yet I was praying for it to come quickly in the final hours of agonal breathing. I also imagined that my first impulse at the time of death would be to pray, but I was very grateful to have a priest present to lead the prayers at the time of death, because I was totally past coherent thought.

  13. I am very excited about diving into this book with everyone. I have seen so
    much in my short 5 years as a priest and 8 total in hospital work as a friar regarding death and its failure to be accepted or embraced by all parties involved. I agree with Fr. Jonah’s remarks of the use of terms like “fighting”, “beat this..” and “battle” totally as the wrong perspective on terminal illness. Christ did not battle his cross but did have victory over death.

  14. No movement. No sound. Total stillness.

    The doctors leave, and the chaplain and the social worker are left. Totally different training! What do you do in that silence? EVERYTHING! Although, it might not appear to be much. No flurry, no sound. And yet an active space. No an empty void of silence, not the absence of life (although it may be), but that holding space. A silent communion. The places in between!

    So many people struggle with silence. Maybe it is even more noticeable in this day of zoom meetings…but people often feel the need to fill up silence…and I guess the silence of death for some the LOUDEST silence. A missed opportunity.

  15. “It seems curious that the people who believe most fervently in divine healing also cling most doggedly to the technology of mortals.”

    I felt this was a jab at people of faith, much like those who mock the sentiment of sending “thoughts and prayers.” If we have a divine “solution,” why do we lean so heavily on the technology of mortals? Is this not pointing to people who believe in a divine healing as hypocrites? Or is that just my defenses?

    1. Thanks for this, Christina. As we go through her book, I think you will find Dr. Dugdale congenial to perspectives of faith and, in many instances, trying to retrieve them. I think her “doggedly” critique may or may not be fair. Insofar as it questions the idea that we should prolong life so as to “buy time” for God to work miracles, I think it’s fair. Insofar as it denies that Christians may sometimes have good reasons to continue care that others may fail to recognize, I think it’s not. It seems to me that her meaning is more the former, but I share your sense that she may not sufficiently appreciate the latter.

  16. What a joy that Dr Dugdale is such an engaging writer. Her book has a great opening, that makes the reader feel part of the dramatic ,adrenaline packed resuscitations in an emergency room.
    The first question is about the authors “regret “at not allowing Mr Turner to die well.
    I agree with your premise she regrets the system and the culture she is a part of. I am sure when she dreamed of becoming a doctor and saving lives, she had no idea she would be required ,by law, to perform extraordinarily invasive life saving measures on people—that she KNEW were actually in the process of dying and should be allowed to do so gently and with dignity .
    But as a licensed physician, she is not allowed to let that happen ,especially if it is against the family’s wishes ..We are talking major lawsuits, her immediate dismissal, extremely negative publicity for the hospital and maybe the loss of her license.
    Even though my father had a “DO NOT RESUSCITATE ORDER”, I was very clearly and emphatically informed by the ambulance medics that when transporting him to and from the hospital ,they were not bound by that directive and would most DEFINITELY resuscitate him if his heart stopped.
    I think Dr Dugdale is trying to change a system that desperately needs overhauling by showing us a better (ancient) way. Can’t wait to read more…

    1. “none of knew for certain whether his family understood the immensity of his disease…”. I think that since hospitals became major corporations, patients are no longer being cared for by their physicians who have know them and the family for years. Their care is handed over to hospitalists and in training residents who may be well versed in acute care but do not intimately know the patient. I believe that Dr D regrets that she was forced to take part in the resuscitation of Mr W without having a chance to really speak with the patient and family with a multi disciplinary team and make sure that all knew a resuscitation would not lead to a cure or delay for any length of time his ultimate death. Dr. D may just have been the doctor on call that night

  17. Combat language, and the narrative that it imposes on illness really hijacks the storyline. I mean really, if one doesn’t “beat” cancer, are they a failure? The loser? Look at Memorial Sloan Kettering….”More science, less fear.” What does that even mean??? A person may be ashamed to be afraid with marketing like this, and will struggle and suffer with their fear alone or on the inside because of messages like this one.

  18. I fully concur with Father Jonah that Dr. Dugdale’s regret is tied to the way our society and the medical system views death. In that framework, death is something to be ignored or denied. Equally important to me, is to have changed the notion that cancer (or any serious illness) is a “battle” to be fought or something to be “won” Suffering affects each of our lives and it behooves us to do our best to acquire good medical care during times of illness and suffering. But the idea that we are “battling” suggests a “win or lose” situation, and puts an additional, irrational burden on the patient. We are all in God’s hands; there is only so much we can do when we are ill. I suspect that the stillness experienced by the family you attended to this morning, Father Jonah, existed because they had accepted the paradox of death. In my experience of watching family members die, I know that true Christians see death as the welcoming of a bright new life, yet as we each approach death, we can only experience the terror of leaving the only life we now know. Death calls us to total poverty of spirit; in death, we must courageously cast aside our fears and put ourselves in God’s hands.

    Thank you, Father Jonah, for orchestrating this very thoughtful examination of one of life’s great mysteries.

  19. I fully agree that the expression of Dr. Dugdale’s regret is in reference to the entire system and medical culture that too often pushes individuals and physicians NOT to prepare for a more thoughtful and graceful death. Equally important, the language of “battling” with the goal of “beating” cancer (or so many other illnesses) does not fully appreciate the journey of illness and does the sufferer a disservice–as if not “beating” the disease is a failure of some sort. Illness is not a win or lose proposition; the act of suffering itself is not a failure.
    And death IS a paradox—a new life to be beautifully welcomed, while holding the terror of letting go of the only life one knows. Death is a true test of poverty of spirit….we are totally in God’s hands at that moment. I suspect the death you witnessed this morning, Father Jonah, was not as stressful as that of Mr. Turner’s, one that was tragically made worse by repeated attempts at denying the inevitable.

    Thank you for organizing this wonderful exercise in reflection on critical moments in our life’s journey.

  20. I believe communication is key. The Health Care Proxy bill and all its implications should be thoroughly discussed with significant others, meaning family, health care physicians, doctors, nurses. Treating the PERSON with dignity is the primary goal.

    1. Does the Christian tendency towards valuing and preserving our mortal lives and joyfully anticipating eternal salvation have to be a paradox? We are naturally willed to respect the precious gift of life that God has granted to us. Thus, we want to do what is best for the health of our bodies. Although we accept that our mortal death is a question of when and not if, we remain ordered toward self-preservation. Yet, our faith allows us to leap beyond the finality of mortal death and embrace the promise of life everlasting. To the faithful Christian, this “paradox” is simply a beautiful transition from life to afterlife.

      1. Thanks Jacqueline. I think your description of the Christian embrace of mortal life and everlasting life is an eloquent expression of what I called a “true Christian paradox” – truths of our faith that might seem contrary from the outside but are beautifully held together in a faithful Christian life.

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