Category Archives: Books

Lincoln and Children on Remembering the Dead

Evening of Remembrance, City of Hope, March 28, 2018

(Gently edited talk delivered to the loved ones whose family members have died from cancer in the last year.)

Introduction

I’m here tonight, while officially on vacation — which may seem at first glance to be an odd way to spend my time away from work. Instead, I see it as absolutely appropriate to spend it with you, members of our City of Hope family. Like you, I have lost close members of my own family to cancer, including one just this past year, so I’d like spend a few moments of my life sharing my memories with you today. Not as a doctor, but as one of you.
I am reminded of my favorite President, Abraham Lincoln. Like me, he was a man who spent most of his formative years in the state of Illinois, in the state capital of Springfield. Nevertheless, his most memorable spoken words come from his few years outside of the land that proudly refers to itself as “The Land of Lincoln”.
In particular, I’m reminded of some of his words to commemorate the lives of those who died in battle in Gettysburg, Pennsylvania. In a similar way, we’ve all lost people who succumbed to their struggle against cancer.
Asked by David Wills, a lawyer in charge of planning activities, if he would give “a few appropriate remarks”, Lincoln gave his most iconic speech – in a mere 272 words, speaking for less than 3 mins.

This is always a reminder to me that much can be said is a few well-chosen words.

Ironically, within his speech, Lincoln told his greatest lie:

“The world will little note, nor long remember what we say here, 
but it can never forget what they did here.”

While we will never forget what Lincoln said, I hope you will forget what I say here tonight, but never forget what your loved one’s did in their lives. I their impact all around us, displayed proudly along the perimeter of this room.

Today is a day for us to reflect on our loved ones, those who didn’t get to see this day, and to remember those meaningful moments they brought into our lives. I have two members of life to reflect on tonight. I discuss them not to call attention to my own circumstances, but to join with you in reflecting on those we’ve lost.

 

Sharing My Experience

It has been almost 8 years since my father passed away from lung cancer. We had a relationship that was complicated, full of respect, but also including many differences of opinion that led to arguments – arguments that continued until the very end. At the time of his passing, I wrote about this, how challenging it can be for those caring for our loved ones when they are in pain, facing their final moments, struggling to be themselves:

“It’s been a couple of months since my father died. Sometimes I see him in my patients, especially the ones who seem defiant and defensive, those who are most skeptical of my care. Other times, I recognize his struggle in my cancer later in life older patients in my clinic who are dealing with the challenges brought on by cancer.”

“These days, I am more careful to tell my cancer patients and their families about the confusion and danger that may occur…And I’m more insistent about getting a [supportive care consultation for them. I try harder to prepare patients and their families for the possibility of a [dangers in the hospital] and how to avoid them. I tell patients’ families that no matter how exhausting, they should make every effort to spend time with a dying loved one to avoid regrets afterwards. I encourage them to involve grandchildren in the conversation about death and disease. I remind myself that few families are ‘ready’ for their loved one to die, even when given ample notice.”

In general, what I noticed at the time, in when caring for a dying person, it is much more difficult to be a son (or a daughter or a spouse or a parent or a sibling or a lover) than a doctor, when someone is gravely ill and suffering. I try to never forget it, and my heart goes out to you.

This last year, my wife’s sister-in-law passed away from an aggressive colon cancer – she was in her early 40s. She and my brother-in-law have small children, overlapping in age with our own. As she was getting sicker, she felt unable to talk with them, to share in the last moments of her life. She also felt unable to talk with us, which was confusing. Yet is reminded me, again, that every experience of life, including its end, is an individual you one. We have to treat each experience as unique, not a part of a statistical distribution.

In the book, “When Breath Becomes Air”, Paul Kalanathi, a young neurosurgeon dying from lung cancer, explains: “My relationship to statistics changed the moment I became one.”

And children are often our best source of truth. I still remember by one, my older son Xander, who was 7 at the time asking uncomfortable questions.

“Is Grandpa going to die?” he asked me one day.
“Yes, I’m afraid so.”
“Because he can’t breathe?”
“Yes.”
“Like when Harrison couldn’t breathe?”

Uncomfortable silence. Harrison, one of his younger twin brothers, recently had been hospitalized for a severe asthma attack. We had had to rush him to the hospital one night.

“No . . . it’s . . . different,” I stammered. “Harrison has asthma, which we are treating with medicine. Grandpa has cancer, and we don’t know how to treat it.”

Our three young boys understood the situation at various levels. We tried to be honest without scaring them. I was constantly impressed by their adaptability, their honesty and their straightforwardness in offering questions, thoughts and feelings. We could all learn from them.

“So, Dad, Grandpa is going to die.”
“Yes, that’s right. But not for a while.”
“Will we still come visit after that to play with Grandma?”
“Yes. Are you OK with that?”
“Well, Grandpa wasn’t very nice to us anyway.”

Unfortunately, despite his best efforts, that was true. My father was a smart, hard-working, dedicated man who lived his life with serious intensity. But he wasn’t always “fun.”

 

Looking Back, Looking Forth

It is why we are so fortunate, at City of Hope’s Department of Supportive Care Medicine, to have Child Life services, experts in helping adults talk with children about cancer, about the process of having cancer. Our supportive care team is full of people who can help in so many ways. I am lucky to be the Chair of such a wonderful Department.

Returning to Lincoln, who summed up his famous address so aptly, focused on the survivors and looking ahead, a call to those among us who are left behind in the wake of a family member who has died. “It is for us the living, rather, to be dedicated here to the unfinished work which they who fought here have thus far so nobly advanced. It is rather for us to be here dedicated to the great task remaining before us — that from these honored dead we take increased devotion to that cause for which they gave the last full measure of devotion.”

It is perhaps appropriate that children are so often still asked to memorize these words for school. We can learn so much from our greatest President and our children.

And that’s how I’ve seen my role since then, to be devoted to the cause of helping bring meaning to people’s lives when they have cancer, to help their families, friends, loved ones and colleagues to cope with the losses, and to carry on the commitment to make everyone’s lives a little better.

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Filed under Aging, Books, Chicago, City of Hope, Civil War, End of Life Care, Lincoln, Palliative Care

New Year, New Decisions

Studying Choices and Making Choices
I love studying decision making.  But it tends to inhibit my own ability to choose — as if making my own decisions should be perfect, knowing what I do about all the ways to make mistakes.  This year, has tested my willingness to trust my own decision-making processes.  It was high time for me to put my own “skin in the game” and live according to some consequential choices.  Unlike the “experts” on TV, who rarely review their prior predictions, yet blithely offer more  for the coming year, I prefer to start each new year by rethinking the prior one.
Since I am a decision scientist at heart, I don’t make resolutions at the start of a New Year.  Instead, I choose 1 or 2 goals to embrace and 1 or 2 bad habits to drop.  Last year, I had two positive goals — to be better about priority setting and to smile more.  Similarly, I had two negatives to eliminate —  to avoid having frustration with people boil over into anger and to waste less time watching  sports, especially the NFL.  Both major commitments, to set priorities and avoid anger — contributed to the major decision to uproot my family and take a new job across the country. My increasing frustration with work led to less anger and more reflection on why I was angry. This led to a recognition that I needed to change my work situation. Not necessarily to leave my position at the University of Chicago, but to make clearer my priorities to people — honestly and not angrily.
Choices from 2017
This has been an amazing and surprising year, and this last day of 2017 is no exception, as I have another hour to wait for midnight to arrive. Despite a nearly lifelong desire to live in Southern California — ever since being a 16 yo lifeguard listening to the Beach Boys in rural Illinois — I had assumed I would never leave the Midwest. Yet, here I am, still waiting almost two more hours to ring in the new year, after a spending the day in 70 degree weather Pasadena, California!
This led to exploration of my options, including the one here at City of Hope. With the support of my wife Tamra, and the willingness of my boys Xander, Harrison and Austin, I decided it was time for a major change. They’ve all been fantastically supportive, even when we lived apart for the first 3 months of the transition.
It was a great decision for me — no regrets. Yes, I do still miss many of my Chicago colleagues, but not the weather. My new home office, a stand-alone structure on our new property, with a beautiful view out to the San Gabriel Mountains, is something I thought I’d get when I retired. The commute is easier, and I’ve learned so much new about a lovely part of our country. The boys have adjusted heroically to their new school situation, especially Xander, who has embraced high school and the challenges of adolescence with a maturity I didn’t know he had.  Seeing him do this reminded me of the difficulties I had moving a much shorter distance as a similar time in my life.  It is delightful seeing him handle it much better than I did.
Choices for 2018 
It’s time for setting some goals for this year, a positive one, for a new capacity to realize, and a negative one, to drop (or at least minimize), to create room for growth.  My positive one is to wright creatively more often, to express myself through words more freely, honestly, and boldly.  The people I admire most, with the possible exception of my patients suffering with advanced cancer nearing the end of their lives, are writers.  It is why I treasure my library and buy old books — to remind me of the treasures of the past. But it intimidates me to try to do this myself. But as I close in on 50, it is high time for me to embrace my own muse.  My negative goal is to reach out more to others, to be less passive about my relationships.  Rather than wait for others to connect, to seek connections myself.  Both of these are rooted in my commitment to make better choices, to live that which I so often study.
William Dale
Dec 31, 2017

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Micro Review: The Crossing

Just finished the latest from Michael Connelly, The Crossing, adding it to my bookshelf that contains every one of his novels in hardback. He is the most consistently high-quality hard-core detective-thriller novelist alive, and belongs in the all-time top 10.

He has a unique ability to combine a logically-rigorous plot with a consistency of purpose in his characters. Much like the experience of the best magicians, one never notices the sleight of hand that guides the action, even when one is looking for it. His lead character, Harry Bosch, combines a hardened righteousness for justice with a deep humanity for the most vulnerable that ultimately wins the day. One deft touch in this book is the vulnerability Harry displays as a single-parent, trying to reach out to his teen-aged daughter, while struggling with his own confusion about her inner life.

For those looking for a last minute gift, or for someone receiving the right gift card, I highly recommend this, or any other, of his novels.

 

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Existential Pain and History

mte5ndg0mdu0otg3mjq1mdcx“I am a dead man!” Alexander recognized immediately that his condition was mortal.

At first, the patient suffered such exquisite pain that Dr. Hosack did not strip off his bloody garments…When [the patient] complained of acute back discomfort, [the doctor] and other attendants took off his clothes, darkened the room, and began to administer [medicines] to dull the ache.

[The patient] was preoccupied with spiritual matters…No sooner was he brought to the Bayard house than he made it a matter of urgent concern to receive last rites from the…Church.

When [the pastor] entered the chamber, he took [the patient]’s hand, and the two men exchanged a ‘melancholy salutation’… He explained that…”It is a principle in our churches never to administer the Lord’s Supper privately to any person under any circumstances.” [The patient’s] friends thought it heartless to refuse a dying man’s last wish.

As befits a great orator, Alexander roused himself for one last burst of persuasion.

At that point, [the pastor] relented and gave holy communion to Alexander, who then lay back serenely and declared that he was happy.

——————-

One common felt pain for patients at the end of their lives is existential or spiritual pain. Though difficult to define, most of us practicing palliative medicine recognize it when we see it. The proper intervention for it is not additional opiates, but rather appropriate spiritual support.

It always impresses me, when reading history, just how often our common humanity binds us across time. The patient above is Alexander Hamilton, lying on his death bed following his infamous “Interview at Weehawken” with Vice-President Aaron Burr . This slightly edited account, taken from Ron Chernow’s masterful biography, Alexander Hamilton, is a dramatic rendering of a man in existential crisis at life’s end. Hamilton recognized instinctively, as he so often did, his need for spiritual input to his pain. Unfortunately, in today’s medical world, we too often fail to recognize this need, delivering the wrong intervention, in the form of another dose of dilaudid, to patients needing spiritual uplifting.

This is not the first time I’ve noticed this in reading through historical biography. U.S. Grant eloquently describes a palliative approach to end-of-life care, as he completes his famous Memoirs while dying from head-and-neck cancer. John Adams describes a receding of the fear of dying, to be replaced by a fear of dementia. Human life, and death, resonates across the ages.

As I prepare for another stint on our Supportive Care Unit, a typically draining two weeks full of existential pain, I find reflecting on our common humanity, and the special role physicians are privileged to play in it, helps sustain me through the experience.

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Visiting Joshua Chamberlain’s House (Part 1)

My second favorite historical figure from the Civil War, after Abraham Lincoln, is “the fighting professor”, Major General Joshua Chamberlain.  Like many, I became a fan after reading the classic Michael Shaara novel Killer Angels about the Battle of Gettysburg, in which then-Colonel Chamberlain plays a starring role as the rhetorician-turned-soldier who saves the union army on Little Round Top.  Like some Nietzchean philosopher-warrior come alive, he “refuses the line” at the far end of the Union left flank, with a desperate bayonet charge down the rocky hillside, all while contemplating the meaning of it all.  Straight out of central casting, what academician wouldn’t salivate at admiring this action-hero figure?

But was it too good to be true?  Could a rhetoric and religion professor really become a military hero?  The academic skeptic in me just couldn’t rest without separating the rhetorical chaff from the history wheat. In my typical OCD way, I started reading about Chamberlain, Gettysburg, Lincoln, and the Civil War overall in hopes of answering these and other questions. I also made the trip to Gettysburg, stood on Little Round Top – on the very large boulder from which Chamberlain anchored the “wheel” for his company’s charge down the hillside – and tried to imagine that burning hot July 2nd so many years ago.  Would I have been able to measure up?

In addition to spending much time on Little Round Top in Chamberlain’s shoes, while moving about the park, I lingered at two other places that day that invited introspection. The first, not far from Little Round Top was the national cemetery where Lincoln stood to deliver his great speech. It sent chills down my spine to imagine being there that day.  The second was standing in the woodline where the young Confederate soldiers in Pickett’s brigade would have stood, preparing to march across a near-mile long, open field into the teeth of the Union line, looking across the way to tiny copse of trees where the Union lines waited.  How could they do it?  What could possibly motivate them to make that march of death?  Would I have been willing and able to do it?

These questions, and many others, led me to explore a reasonable chunk of the available Civil War literature.  This includes multiple books on Gettysburg, another handful on other battles (and visits to the sites), a dozen or so Lincoln biographies, and another 10 on other significant figures.  Regarding Chamberlain, I’ve read several of his own first-hand accounts of the war he provided, but I haven’t read a full biography.

But I was tingling with excitement about seeing the house he lived in, now converted to a museum about his life.  What items did they have within?  What new facts would I learn about his extraordinary life?

In the next post, I’ll describe the museum visit itself.  As is so often the case, the truth is a little different than what I thought I knew.

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Used Book Stores

Wherever I happen to be, I have a special instinct for finding book stores, especially used book stores.  I love everything about used book stores – the musty smell, the happy clutter, the unassuming people.  The best combine the alarming pseudo-organization of mom’s garage with the anticipatory excitement of digging for treasure.  Heaven on earth!

The first vacation day here in Old Orchard Beach, Maine, my bibliophilic antennae picked up a lovely book nook: Ricki’s Place. It contains a potpourri of items – it’s a motel with beach supplies, games, CDs, wool, kites, needlecraft…and used books in English and French.  There a loose organization to the place, with books piled on shelves in quirky categories — political, French, thrillers, “antiques”, biographies, and sports to name a few.  There are others jammed into milk crates and cardboard boxes, sitting alongside paintings, magazines and various knick-knacks. Several of the boxes are piled in front of the shelves, requiring extra effort to dig behind them to find more books. Obviously, money-making from the books is a low priority.  I was tingling.

As I walk in, an older woman with a cigarette-stained voice greets me from behind a desk piled unevenly with a mountain of…stuff.  “Just looking at the books,” I say.  She says to “have a ball”, and points out that there is “good stuff for beach reading”.  Also, she points out, there is a special deal – if you return any of the books you purchase later, you get a 50% credit to get more books. I wonder: is this the actual Ricki from the sign?  I resist the urge to ask.

I start pawing through the shelves, my 11 year old son waiting patiently, longing after the Stephen King and Koonz novels his parents won’t yet let him read.  The semi-random organization of the books is thrilling; I feel like the Pickers guys from the History Channel, hoping to turn up a treasure among the debris.  There don’t seem to be any prices penciled inside the books, and I’m about to ask, when I come across an orange piece of paper tacked to the wall: a price list – paperbacks $2, hardbacks $4, and “antiques” $6.  Hallelujah!

I have multiple categories in my mind as a surf.  Category 1: Better copies or earlier editions of books I already own and love, like Killer Angles or Battle Cry of Freedom.  Category 2: Books I’ve heard about or by previously-read authors I’ve liked, especially older, out-of-print versions.  Category 3: Extra copies of books I like to give to others, like Ender’s Game, The Poet, or Fountainhead. Category 4: Genuine collector’s items, older books, especially first editions, that I can add to my collection that includes a first edition of U.S. Grant’s Memoirs and Mark Twain’s Roughing It.  As I’m squatting down like a catcher behind the plate, sifting through the stacks of the “antiques” section, my son walks up, looks at the titles over my shoulder, “Those are boring.”

Over the next hour or so, I turn up three treasures I can’t resist. From Category 2, I find two things. First, having just finished Peter Matthiessen’s magisterial Shadow Country, I turn up a nice paperback version of his National Book award-winning Snow Leopard. Score!  Also from Category 2, I discover a very nice, nearly pristine first edition, of The Reckoning by David Halberstam, author of Best and the Brightest fame.  As a bonus, the volume is likely worth more than the price as a collector’s item alone. Boom!  Finally, from Category 4, sitting randomly in a box off to the side, rubber-banded together, are three volumes of high-quality early editions (1885, 1886) of books by the writer and father of a future Supreme Court Chief Justice, Oliver Wendell Holmes, Sr.  While not hugely valuable, they are worth far more than the $18 they will cost me and make a lovely addition to my collection. Booyah!

Ready to check out, it takes some time for me to catch the addition of the gravelly-voiced woman in charge.  She starts ringing me up, reminding me of their half-price trade-in deal.  Half-way through the transaction, she gets distracted by a phone call and wanders off talking on her cell.  She returns, and as she’s admiring the Holmes volumes, she stops suddenly to yell past my shoulder at a kid standing in the doorway, which is causing the tone-alarm to chirp repeatedly.  Someone from the back of the shop yells to her, “Ricki, you have to take care of that!” confirming that she is the namesake owner of the place.  She then checks me out, including change with several $2 bills, and offering to put the Holmes’ volumes in a separate bag to protect them.  I happily accept, and turn to go.  My son says, “finally” and we head out for the day.

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