From the early 1970s until I retired in 2013 I lectured on ‘death and dying’ to medical students, initially at Charing Cross HMS, then the Middlesex HMS, and finally at UCL Medical School (strange that all but the last no longer exist, having been incorporated into, or swallowed whole by, Imperial College and UCL respectively). I am blogging on this for one simple reason: I regularly read out a poem to my students – which I’ve just rediscovered in a draw in my cluttered study – that relayed something very important and affected some students sufficiently that they asked for copies. I reproduce it below, with a few comments; but I’d better set the scene.
The framework of my lecture remained much the same through the years, though I updated the empirical research I drew on. From memory, the core messages I wanted to impart featured the following:
- We have seen in the West an historical shift from traditional ‘quick’ to modern ‘slow’ dying, as the causes of death, general and medical cultures, and the capacity to treat life-threatening disease have changed.
- Death in the West has moved significantly from the community into medical institutions and facilities; death and dying are perhaps less ‘familiar’ than they were.
- There are marked differences in inter- and intra-cultural traditions, interpretations of, and practices around death and dying.
- Because people and cultures differ, we should be wary about specifying and enacting specific criteria for ‘the good death’. Guidelines ok, inflexibility not.
- Death in modernity is no longer a simple biological fact (eg cessation of heart beat), but a contested ‘moment’ (eg when is a brain dead?), and the announcement of death can be influenced by social considerations like medical convention or expedient or organ donation or harvesting.
- Slow dying ‘typically’ (but not of course always) has a discernible trajectory, starting with denial and ending in a kind of resignation or reconciliation.
- Slow dying also brings opportunity (eg for kin to get things sorted) and challenges (eg around the timing of visits, the more so since families are often geographically spread).
- Dialogues around death can be difficult and doctors quite frequently do not do what, when asked, they say they do: in short, they have a tendency not to make themselves available for respectful, open dialogue with patients who seek it (eg by leaving it to colleagues). This is understandable but poor practice.
- We must recognise that treating and caring for dying patients requires health workers to have their own coping strategies (a matter of surviving day-to-day) , which may well include humour etc.
I suspect I’ve missed out some messages as I type in a local café, but the above gives some bare bones. They serve also to introduce the poem, which focuses on the critical, unspoken and often neglected fact – as health workers cope – that each patient is a person; and in the case of an elderly patient, a person with a protracted, unique but invisible personal history. Very understandable medical and nursing rituals, necessary for institutional as well as personal coping, can erase, ‘absent’, personhood.
What do you see, nurses, what do you see?
Are you thinking, when you look at me –
A crabby old woman, not very wise,
Uncertain of habit, with faraway eyes,
Who dribbles her food and makes no reply
When you say in a loud voice – “I do wish you’d try.’
Who seems not to notice the things that you do,
And forever is losing a stocking or shoe,
Who unresisting or not, let’s you do as you will,
With bathing and feeding, the long day to fill.
Is that what you’re thinking, is that what you see?
Then open your eyes nurse, you’re not looking at ME …
I’ll tell you who I am, as I sit here so still;
As I rise at your bidding, as I eat at your will.
I’m a small child of ten with a father and mother,
Brothers and sisters, who love one another,
A young girl of sixteen with wings on her feet.
Dreaming that soon now a lover she’ll meet;
A bried soon at twenty – my heart gives a leap,
Remembering the vows that I promised to keep;
At twenty-five now I have young of my own;
A woman of thirty, my young now grow fast,
Bound to each other with ties that should last;
At forty, my young sons have grown and are gone,
But my man’s beside me to see I don’t mourn;
At fifty once more babies play ‘round my knee,
Again we know children, my husnband and me.
Dark days are upon me, my husband is dead,
I look at the future, I shudder with dread,
For my young are all rearing young of their own,
And I think of the years and the love that I’ve known;
I’m an old woman now and nature is cruel –
‘Tis her jest to make old age look like a fool.
The body is crumbled, grace and vigour depart,
There is now a stone where once I had a heart,
But inside this old carcass a young girl still dwells,
And now and again my battered heart swells.
I remember the joys, I remember the pain,
And I’m loving and living over again,
I think of the years, all too few – gone too fast,
And accept the stark fact that nothing can last –
So open your eyes, nurses, open and see,
Not a crabby old woman, look closer, nurses –
See ME!
It’s a poem that some teachers on the circuit grew overly familiar with, to the extent that it became something a cliché for them. Not for me. I confess that reading it aloud to 200+ medical students in a UCL lecture theatre it was always a bit of a challenge to stop my voice cracking towards the end. And it was comforting when, as invariably happened, some students approached or emailed me afterwards to request copies.