final exam

Final Exam is a searing indictment of the way in which the medical establishment often fails to provide palliative care for dying patients. The introspective Chen puts her own behavior under the microscope as well; she admits that she has avoided giving her dying patients the time and treatment that might have made their final days more meaningful and less painful.

Medicine is "a profession made attractive by the power to cure," says Chen. Few medical students yearn to care for the dying. However, as the population ages, more and more people will pass away after a prolonged illness. Physicians play a role in "shepherding the terminally ill and their families through the intricacies of the end." Chen calls this ability to help guide patients through end-of-life illnesses their "final exam." Unfortunately, most doctors, until now, would earn a failing grade.

There are a number of obstacles that prevent physicians from helping and comforting the terminally ill: many physicians (and laymen) have an aversion to death; some doctors believe that getting too emotionally involved with patients may lead to a loss of objectivity; since medical schools have traditionally avoided discussing end-of-life care with their students, most doctors are poorly prepared to deal compassionately with their dying patients. Fortunately, new programs are being established in a number of medical schools across the country that, one hopes, will help doctors treat both the living and the dying with equal skill.

Final Exam is divided into three sections: "Principles" describes how medical school teach their students to approach death; "Practice" shows how the clinical work that a doctor performs each day influences his attitude towards death; "Reappraisal" is Chen's look at some hopeful signs that end-of-life care is at last being taken seriously in medical schools and hospitals.

Chen culls examples from her fifteen years of clinical experience to illustrate her points. There is a haunting anecdote about Joseph and Juliette, an elderly couple who had been married for over fifty years. They were childless retired teachers and virtually inseparable. When Juliette developed an intractable pneumonia during a frigid Chicago winter, Joseph was bereft. He stood by helplessly while his beloved spouse deteriorated. Juliette passed away after futile antibiotic treatment, dialysis, and the use of a ventilator left her little more than a shell of her former self. Juliette's doctors edged away from her more and more as her condition worsened. When his wife died after nearly four weeks in the hospital, eighty-five year old Joseph shuffled off alone, with no one to offer him consolation or guidance. Juliette's physicians lost interest in her case when they saw that they could not save her.

"Preparing for death may be the most difficult exam of all, but it is one that will, finally, free us to live." What will help physicians pass this final and extremely important test? There are some promising ideas that are changing the face of patient care. Specially trained doctors and nurses will routinely discuss diagnoses, prognoses, and treatment with dying patients and their families. When a patient is clearly failing, the medical team will provide palliative care to relieve the patient of her physical pain. The team will also discuss with the patient and her relatives what options they have to make her last weeks more comfortable. Although Chen's prose is elegant and heartfelt, Final Exam is not easy to read because of its bleak subject matter. However, it is necessary for all of us to be more aware of how we, as a society, have failed to treat our dying with the love and respect that they received when they were healthy and fully productive members of their communities.