Sunita Puri, a palliative care attending physician, educates
and illuminates the reader about how conversations about end of life goals can
improve quality of life, not just quality of dying, in her memoir, That Good
Night: Life and Medicine in the Eleventh Hour. Thirteen chapters are
grouped in three parts: Between Two Dark Skies, The Unlearning and Infinity in
a Seashell. The arc of the book follows Puri as she is raised by her anesthesiologist
mother and engineer father – both immigrants from India – Puri’s decision to
enter medical school, her choice of internal medicine residency followed by a
palliative care fellowship in northern California and her return to practice in
southern California where her parents and brother live. Besides learning about
the process of becoming a palliative care physician, the reader also learns of
Puri’s family’s deep ties to spirituality and faith, the importance of family
and extended family, and her family’s cultural practices.
Puri writes extensively about patients and their
families, as well as her mentors and colleagues. She plans and rehearses the
difficult conversations she will have with patients in the same way a proceduralist
plans and prepares for an intervention. She provides extensive quotes from
conversations and analyzes where conversations go awry and how she decides
whether to proceed down a planned path or improvise based on the language and
body language of her patients and their family members. We visit patients in
clinic, in hospital, and at home, and at all stages of Puri’s training and
initial practice. Some of the most charged conversations are with colleagues,
who, for example, ask for a palliative care consultation but want to limit that
conversation to a single focus, such as pain management. We also learn of the
differences between palliative care and hospice, and the particularly fraught
associations many have with the latter term. She feels insulted when patients
or families vent by calling her names such as “Grim Reaper” or “human killer”
(p. 232), but understands that such words mean that more education is needed to
help people understand what a palliative care physician can do. As a mediator of extremely difficult conversations, where
emotions such as shame, guilt, fear, helplessness and anger can swirl with love
and gratitude, Puri finds the grace to acknowledge that all such emotions are
part of the feelings of loss and impending grief, and to beautifully render her
reflections on these intimacies: “Yet although I am seeing a patient because I
have agreed that they are approaching death, if I do my job well, what I
actually encounter is the full force of
their lives.” (p. 206) Having met many dying people she notes: “Dying hasn’t
bestowed upon them the meaning of life or turned them into embodiments of
enlightenment; dying is simply a continuation of living this messy, temporary
life, humanly and imperfectly.” (pp 221-2)
