Go Gentle into That Good Night

Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light.

Though wise men at their end know dark is right,
Because their words had forked no lightning they
Do not go gentle into that good night.

Good men, the last wave by, crying how bright
Their frail deeds might have danced in a green bay,
Rage, rage against the dying of the light.

Wild men who caught and sang the sun in flight,
And learn, too late, they grieved it on its way,
Do not go gentle into that good night.

Grave men, near death, who see with blinding sight
Blind eyes could blaze like meteors and be gay,
Rage, rage against the dying of the light.

And you, my father, there on the sad height,
Curse, bless, me now with your fierce tears, I pray.
Do not go gentle into that good night.
Rage, rage against the dying of the light.

--Dylan Thomas, 1914-1953

New Years Eve, a busy emergency department, and in comes a 96 year old man, straining to breathe, yelling “Hey! Hey! Hey! HEY!” from behind his oxygen mask. He was sent in, from dialysis, because—well, because they couldn’t take his yelling anymore. He said he was in pain. He ALWAYS says he is in pain. He probably always IS in pain.  He’s “full code” and well known as someone whose family wants “everything done”.

This, right after the 95 year old man so demented he can’t give me his name, brought in because he was vomiting blood. His family had to cancel hospice to bring him in. I stare at his blood covered face, child-like liquid-brown eyes staring back at me, trusting. But, trusting me to do what? To put a tube forcefully down his nose to suck the blood out of his stomach to try to determine whether he is still bleeding? To put a large line in his neck, making him lay flat, struggling to breathe, while I dart his internal jugular vein with a large-bore needle? To call in the specialist to put the camera down his throat to see if the bleeding can be stopped?

What do I owe these men, these fathers and grandfathers, whose family want me to “help them!” What is “help” in this context? I’m pretty sure it’s not what their children think it is. I’m pretty sure it’s not forcibly holding down patients who, like toddlers, have no idea why we’re doing what we’re doing, to put in IV lines, urinary catheters, nasogastric tubs or breathing tubes. I’m pretty sure it’s not tying them down and drugging them to get scans or other studies. I’m pretty sure it’s not giving them sedating medications to make them too tired to object or fight the constant assault upon their bodies to give them, what? A few more days or weeks of life spent in misery?

In his seminal article “How Doctors Die” in 2011, Dr. Ken Murray told the world at large what doctors already know, we don’t want for ourselves what we give to our patients. When we are confronted with a terminal diagnosis, we rarely choose the last ditch radiation or chemotherapy. Instead, doctors choose to go home, put our affairs in order, and die with as much grace and dignity, and as little suffering, as we can manage. We die at home and with our family, with as little interference from drugs, surgery and radiation as humanly possible. We die with so very little of what we give our dying patients, that it begs the question “Why?”

Why do we give our patients everything, when we want none of it? Is it because we know what “everything!” actually means? In terms of suffering? In terms of cost? In terms of loss of freedom and self, and mental functioning? In terms of pure loss of self? Of dignity? Of enjoying the last phase of life to which we are entitled?

We understand something about dying that our patients, and their families, do not. Dying is its own moment in time. It has a purpose. Dying can be beautiful, and spiritual and deeply moving. Or it can be ugly, and painful, and very very lonely.

That’s what dying in the hospital is like. Ugly, and painful, and very very lonely. We know, because we have seen it again and again. The nurses, shaking their heads, giving the patient with metastatic brain cancer IV antibiotics to stave off the pneumonia that could, at last, end their suffering. The neurosurgeon, angry, because she knows, knows, she told the patient, and their family, that their cancer was hopeless—yet there they are in the emergency department wanting someone to stop the dying. The emergency physician, heart-broken, putting in a breathing tube on a still conscious patient, a patient who could be hearing their loved ones say good-bye, but instead will be sedated heavily just to tolerate the tube. All so that they don’t die today, right now, this minute—but instead some future date. Some future date where the grief isn’t this day, right now, this minute.

I have always loved Dylan Thomas, particularly the poem, “Do Not Go Gentle into That Good Night.” I love its cadences and its rhythm. I love its fierce and powerful exhortation to live, the words at once jarring and extorting the impossible—to live, to fight death, to rage against its very inevitability.  What I particularly love about it is that within all that beauty is a stark, harsh, truth, the son wants his father to fight death not for the father’s benefit, but for his own. He is unready for the grief he will feel at that, final, end, and so his father must fight what he cannot. It is both transcendent love, and selfishness—as it always is with children and parents. It is the truth at the heart of “The Giving Tree” by Shel Silverstein, which is far harder to read for parents than it is for the children it’s supposedly for.

Death at an advanced and well-lived age is that very last moment parents can give to their children. When all that is left of Mom or Dad is the stump of the tree, having already given their fruit, their leaves and branches, and, finally, their very trunk.  Now, those children, themselves grandparents, fearing that at long last they will be alone, hold onto that stump until they can hold no more. But, it is, in the end, unkind and unfair to deny our parents that gentle, wise and peaceful death.  

Ultimately, it is on each of us to decide how we want to die. Will we rage against the dying of the light? Will we hide from the very idea and let someone else decide for us? Will we die surrounded by strangers, with tubes in every orifice? Or in gentle harmony with the seasons of life, surrounded by our loved ones, in little pain with a quiet “oh!” as we discover that this end, too, has its purpose?

In my time, I intend to go gently into that good night.

As, I pray, will you.