I think about death all the time.
I used to think about birth all the time. This is because I used to work with wombs; for years, I worked exclusively in obstetrics and gynaecology. Then I became a palliative care doctor.
I have, as my mother delights in saying, moved from wombs to tombs.
I confess, though, for conversation-making purposes, I am more likely to introduce myself as an obstetrician. It is almost guaranteed to generate an “awwwww”, whereas palliative care invariably leads to a solemnity which is not always convenient. It takes time to explain that palliative care is not simply about helping people die. In fact, it is all about helping our patients live as well as possible, before they die.
We do this by helping with symptom management, including but not limited to pain, nausea and shortness of breath. But good palliative care goes beyond this. It should be supportive and enabling, as patients and their loved ones face the most difficult journeys of their lives.
I have often told the story of why I started palliative care training. It was not because I was burnt out. I loved my work in obstetrics and gynaecology, and had the astonishing luxury of a supremely diverse career. My relationships with patients and colleagues alike energised and fulfilled me.
But, in mid-2018, a much-loved aunt told me that she had read a profile of a palliative care doctor in a Malaysian newspaper. Her husband, she said, clearly needed this doctor’s services! She was absolutely correct, but at the time I hardly knew what palliative care was. Three months later, coincidentally, our hospital welcomed the region’s first ever palliative care specialist.
These dual events stirred a curiosity in me. The more I discovered about palliative care, the more I felt drawn to it. I loved the specialty I was in, but palliative care captivated me intellectually and emotionally. Modern medical specialties generally make it their business to deconstruct patients into solvable problems. Palliative care aims to reconstruct them into whole people again, hoping to achieve a better-late-than-never restoration of meaning. Or, at the very least, provide compassionate witness to their experience of loss. (There is a Chinese proverb that illustrates how many patients in palliative care feel: pun gan pat leong. It means that people have effectively lost half of themselves, becoming no longer whole.)
The niggling idea that I should work in palliative care was so persistent that I decided to read the Oxford Textbook of Palliative Medicine. I figured it would either exorcise me of my fanciful notions, or at the very least form a basic test of resolution and mettle.
That enormous text has very rich content, but what struck me over and again was its emphasis on hope. “Hope is an essential assessment and intervention tool in palliative care.”
Simultaneously, I thought: hope is also at the very core of obstetrics.
There are many commonalities between these two specialties that I have been so privileged to practise. I reflect on these, as well as the differences between them, with growing wonder.
I have been present at thousands of births. Each moment the baby emerges, whatever the mode of birth, I am filled with a deep reverence. These are sacred times. One second it is all strife; the next, there is new life. And it is never life in solitude. The new life comes to join us, and in so doing, magnifies us. Possibility stretches ahead – this new creature has potential untold, an infinite number of pathways may eventuate.
I have now been present at many deaths, and I feel a sacredness at these times equalling birth. Unlike birth, however, death heralds the end of potential, a sealing-in of loss. If our patient has left things unsaid or undone, they will now never be said nor done. People most often die the way they live.
In the presence of good palliative care, suffering is minimised, and hope maximised. I believe this with all my heart and mind. Good obstetric care similarly minimises suffering, and maximises hope for a well mother with her healthy baby. Whilst death necessarily entails loss, I have seen that for some at least, there is the balm of a gratitude that prevails. As the life of the dying person ends, those they leave behind may feel a gratitude for their legacy that offers enduring solace.
Plato said that “the greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated”. Palliative care explicitly recognises the importance of spirituality, the soul. Obstetrics and gynaecology does not, but ought to. Both specialties require thoughtful mastery of the technical knowhow. The body must be respected, with evidence-based treatment, even as we remember the primacy of soul.
Ultimately, what begins and ends with the emergence and extinction of life is not organ function alone. We are all traffickers in souls, and within this truth lies mystery and privilege.
• Kae Sheen Wong is a palliative care doctor and obstetrician
