Death and all its friends

And in the end

We lie awake and we dream of making our escape.

Coldplay, “The Escapist”

For the past 5 years, Canadian Family Physician has been proud to publish the winners of the AMS–Mimi Divinsky Stories in Family Medicine awards, presented annually at Family Medicine Forum. Awards are given to the best stories written in English, French, and by a resident in family medicine.

This year’s best story in English, “Only life,” by Dr Ruoh-Yeng Chang (page 66)¹ describes her role providing palliative care to a 20-year-old woman dying of cancer. Dr Chang is repeatedly rebuffed by the patient in her efforts to medically manage the young woman’s final days with the usual proffering of hospital gowns and pain medications until she accepts that “only life” with all its messiness will be allowed in that room.

The best story in French—“Mission”—describes Dr Jacques Pelletier’s experiences as a volunteer physician in Chad (page e64).²

Dr Amandev Aulakh’s “Lessons in teaching” (page 67)³ poignantly describes the experience of gently guiding a medical student through the difficult experience of having a discussion about end-of-life care with a dying man and the sadness that moved them both to tears as they debriefed in a nearby room afterward.

In addition to the stories, each year there is an invited keynote speaker whose task it is to reflect on the winning stories and to put them into context. This year’s speaker was Canadian Family Physician’s Associate Editor, Dr Roger Ladouceur. In “Sunsets” (page e58)⁴ Dr Ladouceur writes about his own journey from certainty about the “rightness” of physician-assisted death to uncertainty about how he will feel about his formerly held beliefs when he is finally confronted by death himself. He ends his essay by asking, “So, who knows what we will actually think when it is our turn?”⁴

The inaugural keynote speaker at these awards in 2010 was Dr Arthur Frank,⁵ and it was to Dr Frank’s writings that I turned when trying to put this year’s stories, as well as the keynote address, into context.

Dr Frank has described 3 narratives that doctors use to understand their work.⁶ The first is the restitution narrative and it has primacy in the storytelling of doctors. It is the narrative in which the doctor is the hero who rescues the patient from disease and restores him or her back to health. It is the narrative that draws many of us who choose medicine into this career and it is imbibed like mother’s milk during medical school and residency.

But there are 2 other narratives that Dr Frank has described and both are more relevant to the work that family physicians will increasingly do as our population ages. The first of these is the chaos narrative, when things don’t go as expected. Anyone who has looked after patients with dementia and their families is familiar with this narrative. The second is the quest narrative, which is “about being forced to accept life unconditionally; finding a grateful life in conditions that the previously healthy self would have considered unacceptable.”⁶ With the increasing burden of complex chronic diseases as we age, it is in the quest narrative that family physicians, our patients, and their families might find solace and meaning.

Death is what all this year’s stories have in common—death and our responses as family physicians to it. What all these stories have in common, too, is the power of the restitution narrative on our subconscious as it tries to impose itself. Of the 3 winning stories, it is only in “Mission” that the restitution narrative plays out.

The restitution narrative has such power that even in the palliative care setting it is often used to bend death to our will—the heroic doctor relieves the patient’s pain and suffering and makes death a dignified experience. Luckily for Dr Chang, her strong-willed patient did not buy into the narrative in play and her overpowering will to live fully to the very end made her the hero of her life story, not the physician. Perhaps the lesson in “Lessons in teaching” is that we cannot apply the restitution narrative when confronted with death, forcing us to have difficult conversations with our patients and their families, and to acknowledge our own feelings of sadness and loss at the death of a patient. Perhaps underlying Dr Ladouceur’s uncertainty about the wisdom of physician-assisted death is the realization that it is yet another example of the restitution narrative at work, imposing itself upon death and the stories we tell about it.

For all our commonality, there is more than one narrative about the work of family physicians and the lives of our patients.

• Copyright© the College of Family Physicians of Canada