Nursing Book Club

Final Exam: A Surgeon's Reflections on Mortality

Hospice nurses have known the value of palliative care all along. Here the author makes a strong case for medical schools everywhere to develop a model for teaching end-stage care so doctors can have the same understanding.

By Pauline Chen, MD; Alfred A. Knopf, 2007
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Reviewed By Christine Contillo, RN, BSN

Book ReviewFinal Exam: A Surgeon’s Reflections on Mortality, by Pauline Chen, is a book that I’d like to see handed out along with every medical school diploma. Chen is an award-winning surgeon who trained at Yale, the National Cancer Institute and UCLA, where she was recently a member of the faculty and named Outstanding Physician of the Year in 1999. Through thousands of surgeries she learned to harvest and transplant livers expertly. What she didn’t learn, because it wasn’t included in the curriculum, was how to talk to her patients about death. This is her first book, and she tackles this issue head-on.

The author wonders if medical students might initially be frightened by mortal illness, but through training begin to believe that their education is the key to conquering their own uneasiness. Still, the patients that they cannot save are seen as personal failures. Unable to admit that skill alone may not be enough to reverse disease, many physicians continue to push for treatment long past the point where cure is no longer an option. She says, “One would assume, then, that oncologists get pretty good at talking with patients about difficult topics. A recent study, however, revealed that more than a quarter of oncologists failed to tell their patients that they had incurable cancer.” Possibly fearing that the patient will blame the messenger, they hope that someone else will do it.

Hospice nurses have known the secret of palliative care all along. Hospice allows terminal patients time to say their goodbyes, put their affairs in order, and die in peace with adequate pain medication. Still, most physicians wait far too long to order compassionate care, doing their patients an injustice in the process.  

Chen’s stories about her patients bring them into the room with exquisite detail. They become unforgettable, especially when she confesses how, if she could, she would go back to change how she handled their treatment. In a perfect world she’d have every doctor learn the value of beginning a conversation about terminal care. She admits to years of turfing to another doctor the job of sharing bad news with a family, and that it eventually became part of her “doctoring repertoire.”  

It’s a nurse who finally brings Dr. Chen up short by reminding her about a particular patient with liver cancer. This young patient, engaged to be married, had suffered for years with ulcerative colitis. The nurse asked her to take “good care of him” when he was finally admitted with end-stage disease. Unable to bring herself to talk to him, Chen finds out later that he ultimately suffered an unproductive full-court code at the time of his death. When she thought about him afterward, he became what Chinese call wan ong kuei — a soul that had been wronged and would search the earth for mollification. Perhaps this book is her attempt to put his soul to rest. If so, she is doing all of us a great favor in the process, building a strong case for medical schools everywhere to develop a model for compassionate end-life care.

Written By Christine Contillo, RN, BSN, a nurse since 1979, has written extensively for various nursing publications as well as The New York Times.

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