To reality TV fans out there, this post is probably old news. However, I recently was alerted to this clip from the TV show "So You Think You Can Dance". This show is a competition where dancers compete, are judged, then eliminated. On Wednesday July 22nd, there was a piece done as a tribute to those battling breast cancer.

The piece was choreographed by Tyce Diorio and preformed by Ade Obayomi and Melissa Sandvig with music by Maxwell's cover of Kate Bush's "This Woman's Work". The choreographer said he was inspired by his friend Michelle's battle this year with breast cancer.

The music is a beautiful accompaniment. Starting with what sounds like crying, the dancers mimic the emotion of sorrow at the diagnosis. The lyrics to the portion of the song played:

Pray to God you can cope
I stand outside
This woman's work
This woman's world
Oooh, it's hard on the man
Now his part is over
Now starts the craft of the father

I know you have a little life in you yet
I know you have a lot of strength left
I know you have a little life in you yet
I know you have a lot of strength left

I should be crying but I just can't let it show
I should be hoping but I can't stop thinking
All the things I should've said that I never said
All the things we should of done that we never did
All the things I should've given but I didn't

Oh darling make it go
Make it go away

There are beautiful moments symbolizing the friendship and strength of those who come along side someone with cancer. The dancer with cancer falls in exhaustion, her partner catches her; she dives out in trust and he catches her; she pounds on his chest in anger, and you watch him struggle privately. Ultimately she rises as he lifts her in resolution onto his shoulders.

Dance is yet another creative way to express emotions and narrative. The clip below is from the episode with some introduction, then the 1:20 min dance, followed by the tearful responses of the judges. Hope you enjoy! Subscribers, if you have trouble viewing the video please go to the original Pallimed post to view.

Warren Zevon was an American singer-songwriter known for his "sardonic wit and blazing intelligence" which he incorporated into his music. Some of his well known songs include "Werewolves of London", "Roland the Headless Thompson Gunner", and "Lawyers, Guns and Money". In 2002, Zevon was diagnosed with mesothelioma. He refused any treatment and started on his final album The Wind.

The Wind features guest appearances from several of Zevon's close friends (Tom Petty, Bruce Springsteen, Don Henley to name a few). The making of the album was made into a documentary for VH1 entitled, Warren Zevon: Keep Me In Your Heart.

When I first heard The Wind, I knew it was Zevon's final album, made while he was dying, and so I listened to it differently than I would other albums. It seems to frequently refer to Zevon's illness (but maybe that's just me). Some songs seemed to contain a lot of regret.

Included on the album is a cover of the Bob Dylan song "Knockin' on Heaven's Door". (Not hard to see how this one relates to dyint.) Another song, "Disorder in the House" (recorded with Bruce Springsteen and winner of a Grammy for Best Rock Performance by a Duo or Group With Vocal), is about a house coming apart and falling down. It starts with the lines:
Disorder in the house
The tub runneth over
Plaster's falling down in pieces by the couch of pain

It ends:
Disorder in the house
All bets are off
I'm sprawled across the davenport of despair
Disorder in the house
I'll live with the losses
And watch the sundown through the portiere

Below is "Keep Me in Your Heart" also from The Wind.

Shortly after his diagnosis, in 2002, Zevon appeared on The Late Show with David Letterman as the only guest for an entire hour (most of the appearance can be seen on You Tube). Zevon was a frequent guest on The Late Show. When discussing his cancer, Zevon says,"I might have made a tactical error in not going to a physician for 20 years. It was one of those phobias that really didn't pay off." Later on, Letterman asks Zevon if he knows something about life and death that Letterman doesn't know. Zevon responds, "Not unless I know how much you're supposed to enjoy every sandwich." (The line "enjoy every sandwich" then became one of Zevon's more famous lines.)

Warren Zevon died September 7, 2003, less than two weeks after the release of The Wind on August 26th.

Special thanks to one of my colleagues, Leighton Sweet, for tipping me off about this artist.

William Butler Yeats was both a poet and a dramatist. Born in Dublin in 1865, he was awarded the Nobel Prize in Literature in 1923. Unlike many award winners, his greatest works were actually completed after winning the Nobel with collections of The Tower(1928) and The Winding Stair and Other Poems (1933).

The poem "Death" was published in The Winding Stair and Other Poems. It was actually written in reaction to the assassination of his political friend Kevin O'Higgins, which is referenced in the later part of the poem.

What I really like about W.B. Yeats is that I have to reread his poems a few times to really grasp what he's trying to say.

Death

NOR dread nor hope attend
A dying animal;
A man awaits his end
Dreading and hoping all;
Many times he died,
Many times rose again.
A great man in his pride
Confronting murderous men
Casts derision upon
Supersession of breath;
He knows death to the bone --
Man has created death.

The sentiment in the first part of the poem is that simple profound truth; that we as humans, unlike other animals, are cognizant of our own mortality. As far as we know, birds are not flitting around the sky worrying about death, or even experiencing hope for the future.

It is this fact that allows us the material we write about in this blog. People contemplating death and grief give us music, art, poetry, books, etc.

Although the next line "Many times he died,/ Many times he rose again" may sound like reincarnation, I think more accurately Yeats has something like this in mind, from his poem "Under Ben Bulben":

Many times man lives and dies/
Between his two eternities

There are many symbolic deaths we go through in life, only to rise again and continue.

Although the last portion is in direct relation to his friend, it relates to the inescapable nature of dying. Mr O'Higgins had played a role in the executions of some IRA members, his assassination being in retaliation to this. He said to his wife, "Nobody can expect to live who has done what I've done."

The image of a man looking head on towards certain death, in fact casting scorn at the idea of avoiding or replacing death (casts derision upon/ supersession of breath), may be a maturing from the initial feeling of dread at dying or hope to avoid it seen in the beginning of the poem.

As for the last line that "Man has created death", it's often quoted out of context from the poem.
There are two thoughts I have for this. The first, when thought of with the beginning idea of the poem, that animals are unaware of their own mortality, well then it is we, "man" by our own awareness of dying that indeed we have created the concept of "death". Second, he simply could be referring to his friend Mr. O'Higgins, who by his own admittance, undertook actions that led to his death, thus perhaps he actually "created" his own death?

Any other thoughts?

Jeffares, AJ "W.B Yeats, man and poet" 1996

There is a vast amount of children's literature available about death. I wanted to review one such book I came across recently. It is a visually beautiful book, with sweeping oil paintings depicting the metaphor of death as leaving on a boat. The book "The Goodbye Boat" is by author Mary Joslin and is illustrated by Clarie St. Louis Little.

There are few words in this book, leaving the message to be portrayed visually. Two grandchildren are depicted with their grandmother. At first they are at play in summer by the beach. Then in the sunset a ship approaches. The grandmother waves goodbye and as the climate turns to winter the boat sails away. However as summer comes again the message is clear, with the children once again playing on the beach and happy.


The final phrase of the book, "yet when the boat is gone from view it's surely sailing somewhere new" is meant to provide hope after all of the sadness.

I like that this book gives its message in short words like "wondering", "weeping" and "lonely days". These phrases coupled with the moving pictures would surely help instigate conversations with children reading it.

In fact, in one of the reviews on amazon.com, I noted a reviewer said she read this book to her grandnieces after a death, and they asked to re-read it multiple times, each time asking new thoughtful questions about death.

I also like the various metaphors. The seasons that match the emotional responses is nice touch. The boat metaphor I like better than the "going to sleep" metaphor which can be confusing for young kids. However, this too can be confusing if the child assumes this as concrete fact. As one review pointed out, a child may assume the boat will come back... awaiting their loved ones return.

I also appreciated that the boat was seen approaching, long before the grandmother left on it. Although very much an ideal, it gives the sense that one can prepare and have a chance to say goodbye.

I think if I had to pick my favorite page of the book it would be this one below, with the words "wondering,". I encounter this feeling more often on a daily basis, doing palliative medicine work, than any of the other expected feelings of sadness, anger, etc. You can see the sad frustration and unknown in the expressions of the kids as well as the grandmother herself. Wondering is experienced by both patients and families, as well as with those of us in the medical world.












Joslin, Mary. "The Goodbye Boat" Eerdmans Books For Young Readers: Grand Rapids, Michigan. Copyright 1998

Eulogy is a 2004 comedy surrounding a "dysfunctional" family dealing with the death of the family patriarch. I've seen it described as a "black" or "dark" comedy. Probably fits.

The film begins with the family finding out about the death of Edmund Collins and then heading home to his funeral. Some members are upset over the death, some are upset about the inconvenient time. It is focused around the granddaughter Kate, a college freshman (and possibly the most normal person of the group) who has been asked to deliver the eulogy at her grandfather's funeral. Amongst the group of 4 children and 6 grandchildren, Kate seems to be the only one really concerned over Edmund's death. The rest of the family seems preoccupied with their old fights and issues.

Meanwhile, Charlotte, the widow, who is seemingly distraught over the death of her husband and her children feuding, attempts suicide. More than once.

During the course of the film, secrets come out about the surviving family members and about the departed. If I had to sum up the theme of the movie it would be, "We may be screwed up but in the end we're family." I'm not going to give away the end, but Kate finds a way to eulogize the grandfather who no one really ever completely knew. I like the funeral scene.

This film made me think a lot about dysfunctional families. It's not a term I use lightly. After seeing a lot of different types of families, I have begun to think that what we call "dysfunction" is often just functioning differently than the norm. What is normal anyway?

Time again to pick a theme and look at some contemporary artwork that deals with it. Having just posted about digital afterlife, I began looking for current artists' material on the subject.

As with the topic of "pain" art, the idea of "afterlife" is very subjective. If anything, these works all have a bit of the surreal to them. As they should; unlike pain, none of us has been able to live through what comes after life and then document it from personal experience. These are works of the imagination, and so being, can be playful at times.

This first image entitled "Afterlife" is a mixed media piece by Donald McIntosh. There is a body on the left, separated from the complicated gears/machine like area on the right.


I came across an art site on the web that chooses themes for their artists to contribute to. They actually have an entire art pack dedicated to the theme "afterlife". The site is called Slashtree, and of those in the collection, I've picked out my two favorites to display. The first is the piece entitled "Afterlife" by Maciej Mizer. A link to the full image here shows how detailed this work is. A very imaginative creation with people, homes, castles, hot air balloons and even a McDonald's sign.



This next work from Slashtree, although not entitled "afterlife", asks the question behind the concept. The title of this work is "What will it be?" by Dominik. The subject in this work swings or dances, giving the viewer a sense that the answer to the question is at least playful and nothing to be scared of.



Finally, a bronze sculpture entitled "Afterlife Afterthought" (2005) by artist Emil Alzamora. This 8 foot structure to me depicts the out-of-body concept so many people speak about in near death experiences. Both images are of the same piece.

Just a small representation of contemporary works contemplating afterlife. In the future we'll look at some historical works of art with the same theme. As you can imagine the historical works have quite a different approach.

I came across this song while researching for the Top 10 List. Seasons in the Sun was a remake of the Belgian song by Jacques Brel "Le Moribund" or "The Dying Man". This better known English version was recorded by Terry Jacks in 1974.

I find it interesting that, while the English version was a remake, Jacks changes a lot of the meaning of the song.

Goodbye to you, my trusted friend.
We've known each other since we're nine or ten.
Together we climbed hills or trees.
Learned of love and ABC's,
skinned our hearts and skinned our knees.
Goodbye my friend, it's hard to die,
when all the birds are singing in the sky,
Now that the spring is in the air.
Pretty girls are everywhere.
When you see them I'll be there.
We had joy, we had fun, we had seasons in the sun.
But the hills that we climbed
were just seasons out of time.
Goodbye, Papa, please pray for me,
I was the black sheep of the family.
You tried to teach me right from wrong.
Too much wine and too much song,
wonder how I get along.
Goodbye, Papa, it's hard to die
when all the birds are singing in the sky,
Now that the spring is in the air.
Little children everywhere.
When you see them I'll be there.
We had joy, we had fun, we had seasons in the sun.
But the wine and the song,
like the seasons, all have gone.
Goodbye, Michelle, my little one.
You gave me love and helped me find the sun.
And every time that I was down
you would always come around
and get my feet back on the ground.
Goodbye, Michelle, it's hard to die
when all the bird are singing in the sky,
Now that the spring is in the air.
With the flowers ev'rywhere.
I whish that we could both be there.
We had joy, we had fun, we had seasons in the sun.
But the stars we could reach
were just starfishs on the beach



Now compare those words to that of the original. (Sorry not the best video but it has English subtitles, which, as I speak no French, I found very helpful.)

In the French version of this song, it was meant to be understood that this was a man about to commit suicide (although he doesn't quite come out and say it). In Jacks version, he could have been dying of anything. Jacks also takes out the infidelity that plays a huge part in the French version.

I think Jacks takes all of the bite out of the song. When I first read the words to Le Moribund, I thought it seemed like a suicide note. The singer is saying goodbye to some of the people in his life and seems to be almost blaming others. Seasons in the Sun didn't seem like this at all. Just a man saying goodbye. Not nearly so dark.

Digital technology is changing just about everything we do, including death.

Here's an example of a facebook memorial. This example is of a specific memorial created as a group after this person died. People join and leave comments of condolence. The other way memorials are created are when people leave messages on the deceased profile page. What many find different in the way of typical condolences is that people then address the deceased personally. These few examples are from an 18 year old girl who died in March of this year in Colorado Springs:

"I hope alls well up there. we're gonna miss you an awful lot down here."
"I walked into church today and thought I saw you walking across the foyer. Just so you know, there's a girl that looks so much like you it's insane."
"hey girl hey. so this morning I had the horror (or pleasure?) of waking up to a giant bushy squirrel. ... obviously I thought of you and our mutual squirrel obsession."

A happy belated 200th birthday to Edgar Allan Poe. (An event with brought out some controversy over which city can call itself Poe's hometown: Boston, Baltimore, Richmond, New York, or Philadelphia. There has also been talk of which city has claim on Poe's remains.)

Poe was born in Boston, January 19, 1809. I think we all know Poe for his horror writings, but he is also contributed greatly to the science fiction genre and is considered a founder of the detective-fiction genre.

To say Poe had loss in his life is an understatement. Both of Poe's parents died before he turned three. He was taken in by a wealthy merchant family, but the relationship with his foster father was often a rocky one and eventually Poe was disowned. His beloved foster mother and older brother both died when Poe was in his early 20's.

At age 27, he married his 13 year old first cousin, Virginia Clemm. Several years later, she became ill with tuberculosis. Around that time, Poe began to drink more. It's thought that his wife's illness was the inspiration for one of his most famous poems, The Raven. Virginia eventually died. The recurrent theme of dying young women (Annabel Lee, Lenore)in his work has been contributed to Virginia's illness and death and to the death's of other women (mother, foster mother) in his life.

After Virginia's death, Poe became very unstable. Two years later, he was found wandering delirious through the streets of Baltimore. He died soon after and the exact cause of his delirium and death has remained a mystery. He was buried in an unmarked grave in Baltimore but his remains were later moved.

Since 1949, the Poe Toaster (an unknown gentleman dressed in black) has been visiting the grave marker of Edgar Allan Poe's original burial site each year on his birthday. He toasts Poe and leaves behind a half bottle of cognac and three red roses.

I'll close with my favorite Edgar Allan Poe poem, Eldorado. (I don't know what that says about me. A sucker for hopeless causes?)

                Gaily bedight,
            A gallant knight,
        In sunshine and in shadow,
            Had journeyed long,
            Singing a song,
        In search of Eldorado.

            But he grew old-
            This knight so bold-
        And o'er his heart a shadow
            Fell as he found
            No spot of ground
        That looked like Eldorado.

            And, as his strength
            Failed him at length,
        He met a pilgrim shadow-
            "Shadow," said he,
            "Where can it be-
        This land of Eldorado?"

            "Over the Mountains
            Of the Moon,
        Down the Valley of the Shadow,
            Ride, boldly ride,"
            The shade replied-
        "If you seek for Eldorado!"

This self-released, indie rock/ambient album's title should grab the palliative medicine community. Peter Silberman spent a year in isolation from friends, then another year to write about his experience in this album that was released March 3rd, 2009.

The tone of the album is dark and dream-like. Silberman creates a symbolic figure named Sylvia...taking inspiration from the macabre world of Sylvia Plath, as well as a fictional Sylvia depicted in the novel "Sylvia" by Leonard Michaels. Both Sylvias have tragic lives, burdened by degrees of mental illness, depression and death. Perhaps it is their illness coupled with their tortured relationships that allows Silberman to draw inspiration... regardless "Hospice" dwells on the ending of a claustrophobic relationship by portraying death, nightmares and illness.

The only clue to the title comes from Silberman's blog of the album's process. He leaves a post with the definition"hospice n 2: a program of medical and emotional care for the terminally
ill".

In the song "Kettering or, bedside manner" we encounter a woman dying of cancer (Memorial Sloan Kettering Cancer Center) and a hired caregiver. The song, in medical terms, has a crescendo/decrescendo flow. It swells, peaks in sound and settles again. You can listen to the song at the artist's myspace page here. The lyrics are as follows:

I wish that I had known in that first minute we met, the unpayable debt that I owed you. Because you'd been abused by the bone that refused you, and you hired me to make up for that. Walking in that room when you had tubes in your arms, those singing morphine alarms out of tune kept you sleeping and even, and I didn't believe them when they called you a hurricane thunderclap.

When I was checking vitals I suggested a smile. You didn't talk for awhile, you were freezing. You said you hated my tone, it made you feel so alone, and so you told me I ought to be leaving. But something kept me standing by that hospital bed. I should have quit, but instead I took care of you. You made me sleep and uneven, and I didn't believe them when they told me that there was no saving you.

The album is definitely dark, with lyrics about waking up in a morgue and being buried alive in "Epilogue". And from "Shiva" the opening line is "Suddenly every machine stopped at once, and the monitors beeped the last time. Hundreds and thousands of hospital beds, and all of them empty but mind." You can read all the lyrics to the album here.

Although just released, the album is getting a lot of press. In fact NPR's All Songs Considered has named "Hospice" as the best album of 2009, so far.

So take a listen and let us know what you think.

Thanks to one of my nurses, Linda, for telling me about this film. Westerns aren't my usual movie fare but hearing about the plot of this one along with the all-star cast (John Wayne, Jimmy Stewart, Lauren Bacall, Ron Howard, Harry Morgan) convinced me to check it out.

John Wayne plays JB Books, an aging gunfighter, who comes to Carson City seeking a second medical opinion. He has gotten the diagnosis of cancer and comes to see a trusted physician, Doc Hostetler (played by Jimmy Stewart). In one of my favorite scenes, Books is told the bad news and is given about 2 months to live. (I couldn't find a clip, but below is the dialogue.)

Doc:Books, every few days I have to tell a man or a woman something I don't want to. I've been practicing medicine for 29 years and I still don't know how to do it well.
Books: Why don't you just say it flat out?
Doc: Alright, you have a cancer. Advanced. [portion removed]
Books: Can't you cut it out doc?
Doc: I'd have to gut you like a fish.
Books: Well, what can you do?
Doc:There's just very little I can do. When the pain gets too bad I can give you something.
Books: But you're trying to tell me is...
Doc:Yeah
Books: Damn
Doc: I'm sorry Books.
Books: You told me I was strong as an ox.
Doc: Well even an ox dies.
Books: How much time do I have?
Doc: 2 months, 6 weeks, less. There's no way to tell.
Books: What can I... What will I be able to do?
Doc: Anything you want at first. Then later on you won't want to.
Books: How much later?
Doc: You'll know when.

In another conversation with the doctor, Books asks about how it is going to go. Doc Hostetler tries to evade the question at first but then tells him "There'll be an increase in the severity of the pain in your lower spine, your hips, your groin. Do you want me to go on? The pain will become unbearable. No drug will moderate it. If you're lucky you'll loose consciousness and until then you'll scream." He goes on to tell Books, "I would not die a death like I just described... Not if I had your courage." This leads Books to try to go out in a blaze of glory. Hastened death by gun fight.

Much of the film is Books coming to grips with his terminal illness, fighting off those who want to take advantage of his death, settling his affairs, and imparting words of wisdom to a young man, Gillom (Ron Howard). Below is the film trailer.

This movie came out in 1976 and it was John Wayne's last film. It came out 12 years after he was diagnosed with lung cancer and 3 years before he died of gastric cancer. In many ways, the lives of Books and Wayne are very similar. Both very famous, facing illness and the end of their careers.

Also, Lauren Bacall (who stars as a sort of platonic leading lady in the film) had lost her husband, Humphrey Bogart, to esophageal cancer many years earlier. I wonder how this effected her performance in the film.

Something interesting from a historical palliative care perspective, they use laudanum (opium mixed with alcohol) for pain control. When Books takes a swig out of the bottle, the question is asked, "That's habit forming, isn't it?" Some things are timeless.

Francisco Goya (1746-1828) was one of Spain's greatest artists and his works have become a chronicle of Spanish history. By painting the aristocrats' idyllic lives in portraits, his paintings serve as a visual account of this important time in Spain's past.

In 1792 however, at the height of his career, Goya contracted cholera with subsequent sequelae of paralysis, partial blindness, vertigo, tinnitus and eventual deafness. Gone were his colorful happy portraits, and what followed were new dark and macabre paintings.

We can get a glimpse, possibly, into his psyche with his etching "?De que mal morira?" ("Of what illness will he die?") (1796-97). The physician depicted as a donkey in a suit may be how Goya viewed the medical community at the time. In the background we see the hooded figures waiting for this gentleman's death, while the physician can do nothing but take the man's pulse.

Although Goya survived his illness, he was left permanently altered. Many believe he suffered an encephalopathy of sorts from the high fevers during his earlier illness causing a degree of madness. Most indicative of this dark period are the "Black Paintings", done at the age of 74, they are a series of 14 works done in fresco style on the walls of his house.

The very method of painting on your own walls, implies a privateness to the pictures. They weren't painted to be viewed by anyone but the artist himself, as a kind of visual diary to the thoughts and images he was experiencing in his older age.

In this series is "Two Old People Eating"(1820), these 2 men both pointing at who knows what, could have been Goya's only companions for his meals. The figure on the right is almost skeletal, and both seem to be taunting the artist.

These next two pictures in the Black Paintings collection framed one of the doors downstairs, with "Two Old Men"(1820) on the left and "A Manola"(1820) on the right. Here we see the possibility of Goya as an old man with the call of death being whispered in his ear. Whereas in the next scene the manola is in mourning clothes, resting on a grave- maybe Goya's? It says much to know Goya painted these on a doorway to which he was forever walking through. Perhaps reminding himself daily of his own mortality.


Providing yet another glimpse into his world, Goya left us with "Self-portrait with Dr. Arrietta" (1820). Once again a commentary on the physician-patient relationship, this time the doctor offers compassion with his embrace and cup of kindness to the artist himself. The haunting figures are still present, but the doctor acts as a barrier of protection. The painting is inscribed on the bottom with "Goya in gratitude to his friend Arrieta for the skill and care with which he saved his life in his acute and dangerous illness suffered..."

Illness abruptly changed the nature of Goya's paintings, just as terminal illness changes the reality of our patients' lives. What images would we see depicted if our patients' narratives could be portrayed, like Goya, in works of art?

For a look at more Goya paintings see the Black Paintings and a large collection at Olga's Gallery.

Image by Getty Images via Daylife

The video is inspired by the Renaissance painting, The Garden of Earthly Delights, (particularly the third panel of the painting representing hell) by Hieronymus Bosch (Wikipedia link has a great close up of the painting when you click on it) and other works of art that depict the fall of man. There is a lot of religious imagery which could represent some of Hetfield's own struggles with religion. A word of warning: This is a heavy metal video and some of the imagery is disturbing. These images do not represent the views or opinions of Pallimed or any of it's writers. Note prominent the fall-of-man themes throughout.


Where do I take this pain of mine
I run but it stays right by my side
So tear me open and pour me out
There's things inside that scream and shout
And the pain still hates me
So hold me until it sleeps
Just like the curse, just like the stray
You feed it once and now it stays
Now it stays
So tear me open but beware
There's things inside without a care
And the dirt still stains me
So wash me until I'm clean
It grips you so hold me
It stains you so hold me
It hates you so hold me
It holds you so hold me
Until it sleeps
So tell me why you've chosen me
Don't want your grip, don't want your greed
Don't want it
I'll tear me open make you gone
No more can you hurt anyone
And the fear still shakes me
So hold me, until it sleeps
It grips you so hold me
It stains you so hold me
It hates you so hold me
It holds you, holds you, holds you until it sleeps
AND IT WONT IT WONT IT WONT IT WONT IT WONT IT KNOWS
So tear me open but beware
There's things inside without a care
And the dirt still stains me
So wash me 'til I'm clean
I'll tear me open make you gone
No longer will you hurt anyone
And the hate still SHAMES me
So hold me until it sleeps

Franz Schubert was a gifted composer who died tragically young. Easily considered among the "greats" of composers, Schubert contracted syphilis in 1822 at the age of 25. He continued to compose, even as his health deteriorated. Many say that the works of his last 2 years became very dark, showing a deeper sense of spiritual awareness, and even a sense of the "beyond".

At the age of 20, Schubert put to music a poem by Matthias Claudius entitled "Death and the Maiden". The lied portrays a maiden begging for death to pass her by, and Death trying to persuade. The words from his song and Claudius's poem are as follows:

Maiden:
Stay away! Oh, stay away!
Go, fierce Death!
I am still young, please go!
And do not touch me.

Death:
Give me your hand, you beautiful and tender vision!
I am a friend, and come not to hurt you.
Be of good cheer! I am not cruel,
You will sleep softly in my arms!

This theme of Death and the Maiden is seen in art as well as music. Usually death is portrayed seducing or tempting a beautiful maiden. The idea that death would be a temptation began earlier in the 1400's when death was portrayed in the Dance Macbre, playing an instrument, luring people to death. Perhaps if Death was a temptation, then humankind could avoid the temptation, and avoid death? Death and the Maiden as a theme also conjures up a feeling of vulnerability in youth, as well as beauty. It leaves us with the feeling that life is fleeting, as beauty can be.

Schubert did an interesting thing. In 1824, a few years after his syphilis diagnosis, as his own mortality became central to himself, he re-worked his original Death and the Maiden lied into a string quartet. The theme, while similar to the original lied, takes on a very agonized and at times urgent tone. We might surmise the urgency he himself felt as he became more ill.

Listen first to the earlier lied by Schubert. This video from YouTube of Marian Anderson singing has a classic Death and the Maiden art image shown in the middle. (For email readers click on the post's title for re-direction to the original to see the video)

Second, here are two short videos I've done from the later string quartet. You'll notice the words from the original lied placed in the video, as well as suggestions to what you're hearing. The first is the maiden and the second Death answering. Hopefully you'll appreciate the dramatic difference in the earlier lied and later quartet and notice that the theme of "Death and the Maiden" took a very personal turn for Schubert.







A few short years later Schubert did die. He was only 31. It is believed he died from complications for syphilis, though some believe he may have died from mercury poisoning, which at the time was the standard treatment for syphilis.

ER premiered Sept 19, 1994 and was the creation of the late Michael Crichton. (Crichton wrote the screenplay for ER based on his experiences as a resident.) On Thursday, April 2nd, after a 15 year run, the series finale aired on NBC, entitled "And in the End..."

I haven't watched ER in many years. I stopped watching shortly after I started medical school because I just couldn't take the medical drama anymore. But I just couldn't help myself from tuning into the finale. When I watched ER in the past, it was not from the perspective of a palliative care doctor. I was pleasantly surprised Thursday to find several palliative care themed plot lines.

First off, one of the main plot lines was actually based on a true story. Executive producer, John Wells, 17 year old niece died from alcohol poisoning in December. This plot line, in which a teenager is brought in after a night of binge drinking, was written to raise awareness about this issue.

Another case involved a gentleman with AIDS brought in for breathing difficulties. After a workup, he is diagnosed with cancer. When the resident brings up chemotherapy to buy him a few more months, the patient refuses saying that for years now he has just been living for all of his friends who have died from AIDS. "I've been trying to live for them, you know, keep their memories alive. But I've had my time. No regrets." He goes on to describe an experience skydiving and hopes that death feels the same.

Resident: Is there anything I can do for you?
Patient: Yeah, there is. I don't want it to hurt.
Resident: We can help with that.

But to me, the most impressive story was that of an elderly MS patient admitted with pulmonary edema and sepsis. (Sorry, I couldn't find a good clip of this. But the full episode can be legally watched on the NBC website here.) The doctor explains to the husband that they can give his wife IV fluids but it will only do more damage to her lungs. When her husband wants more aggressive things done, the doctor explains that even with aggressive treatments her life will only be prolonged by a week or two (He prognosticates while having a goals of care conversation! Is this the first time that has been seen on TV?) and these things will just prolong her pain and suffering. He then says "It's time to talk about how to make her as comfortable as possible." Later in the episode, the husband is upset that his wife has an apneic episode. The nurse explains that irregular breathing is a normal part of the dying process.

One of our readers sent this link of an amazing website devoted to pain. Palliative Medicine is no stranger to pain and the Pain Treatment Topics site has a plethora of information regarding pain topics. What our reader pointed out, however, was the website's gallery devoted to patients' portrayals of personal pain.

The site is quick to point out that many of their pieces are borrowed from yet another website called the Pain Exhibit. The Pain exhibit is devoted to personal artwork related to pain. The brainchild of Mark R. Collen, who himself suffered years of under treated pain, he found that art did more to communicate about pain than words themselves. The site is organized into themes such as "Suffering", "God and Religion", and "Hope and Transformation" to name a few.

What I appreciate most about both websites are the inclusion of statements from the artists. It adds so much more to be able to read something from the person who created the piece and the one suffering from the pain.

I'm including just a few of my favorites here. But be sure to follow the links and do some exploring yourself.

Title: Self Portrait, Green Shirt by artist Sterling Ajay Witt.

Artist's comment: "Pain is the beginning and the end of every day for me. I have suffered from chronic pain for so long that I can't imagine life without it anymore. As by back pain increased and the brace came into my life, I found myself painting an increasing number of self portraits. Through them I try to express a feeling I cannot put into words, attempting to explain the torment I am going through. For me, creating art is just something I do to hemp me survive a life of constant pain. It's as if the paintings have become a record of my pain, giving a face to an otherwise faceless enemy." Copyright 2007 Pain Exhibit (PainExhibit.com)


Title: Chronic Pain - Life Distortion by artist Jenny Greiner

Artist's Comment: "I created my vision of what would represent my chronic pain. Beginning with the "eye being the window to the soul," I showed the clear, yet bloodshot eye, shedding the blood-stained tear. Then I realized that this whole living with chronic pain, is very disorienting. Things can start to spin out of control very easily. This represent my pain and the distortion and confusion it brings to my life." Copyright 2008 Jenny Greiner Http://www.drawthepaw.com

Title: CPII by artist Mark Collen

Artist's Comment: "This sculpture represents suffering from chronic pain." Copyright 2007 Pain Exhibit (PainExhibit.com)



This next piece below was actually featured on the cover of The Journal of Pain and Palliative Care Pharmacology (2007) Vol. 21 NO. 2 but is also found in detail at the Pain Exhibit website here.



Title: A Liar Is Not Believed Even Though He Tells The Truth by artist M.R. Shebesta

Artist's Comment: "The painting is a representation of the flesh being scraped from my body. Shards of metal appear to slide and cut into the fleshy oil painted canvas that is held into place by intricate lacing of fishhooks and taxidermy floss. The painting floats in the center of a custom wood frame similar to the visual effects of primitive tribes' techniques for cleaning and drying animal hides" Copyright 2007 Pain Exhibit (PainExhibit.com)

I think I probably read more obituaries than the average person my age. They're mostly the obituaries of patients I have known. For the most part they are very similar. I've always appreciated the ones that are more creative. I've never thought of them as a form of art and I never really thought about who was writing them (don't families write them sometimes?). I recently discovered the Society of Professional Obituary Writers (SPOW), an "organization created for folks who write about the dead for a living."

I must admit, my first thought was, why? Is there a society for those journalists that write for every other section of the paper? But after perusing their website, their cause became more clear. "We want those who write articles about the recently deceased to regard obituaries as once-in-a-lifetime stories that should be researched, reported and penned with as much care and attention as any other newsroom assignment." Oh my! Well put. Could obituary writers be to journalism what palliative care is to medicine? I suddenly feel very sympathetic to the plight of the obituary writers.

Every year SPOW gives out awards for the best obituaries in different categories, such as Average Joe, Celebrity and even Broadcast media. Since I discovered their website, I've devoted some time to reading some of the award winning obituaries about people I've never met. I have been trying to appreciate them more as an art form, a work of nonfiction. I was amazed by how clear a picture some of these gifted journalists could paint even though I didn't know the subject of the articles.

Below is an excerpt from Fair Thee Well, Ex-Father-In-Law by Daniel Asa Rose (from Obit) which won for the Best Tribute/Memoir/Column (Long):

"So it's easy, is it not? To pick up where you left off. There is no earthly reason to stop communicating with a man just because you divorced his daughter, no reason in the world not to keep the dialogue going ad infinitum. Except one. For this bullying bruiser who was going to live to be 100 suddenly dropped, just like that. Before I could send off my package, this unstoppable man with his burly chest and nasty brilliance was cut down, the private nurse un-caught, the hurtful snare drum of a laugh shut down at last. I had meant to pick up where we left off: Now we were just leaving off. Wesley Love died, and what was music and what was not would have to wait some later debate.

Here's to you, ex-father-in-law. I'm sorry we never recognized each other for what we were. Probably you were not the ogre I thought, just a mortal straining to suck in your gut in your canary yellow La Coste shirt. I was just a kid trying to lock horns with one of the big guys. Why didn't we know that then? Why aren't we all more gentle with each other now?"

Although it's too long to post here, I appreciated Carol Smith's article (which won for Best Average Joe Obit Short) Dying vet planned a final mission.

So to all you obituary writers out there, my proverbial hat goes off to you. You do important work and I hope you have the appreciation and respect that you deserve.

I came across this poem in The Pharos a few years ago. Dr Eugene Hirsch has been writing poetry since medical school. Although his background is in cardiology and geriatrics, He most recently has been teaching an end of life physician education program with residents and medical students in Pittsburgh. His teaching has enabled learners to reflect on their experiences in medicine and that of end of life care.

To the end of her life

Two flights up,
she cradled a swollen belly
in memorabilia,
in the bowels of her bed.

Her sallow face told me
how near to death she must be.

She paused and stared into space,
Asking not for medicine, but for prayers.
I led her to find those she knew.

I'd learned some, not others.
In my confusion, I searched
for a "likeness" of her God
(shaped with the palms of my hands)
to sit there beside her and smile. I led her
to tell Him what she wanted Him to know-
to take away her terrible pain,
to forgive,
to bless.

She wanted never
to be alone again, never
to die each day, never
to really die.

The poem describes an encounter, not unlike ones we've all had. A dying patient requesting a prayer. Instead of walking away the writer does the best he can. There is such honesty in the line "in my confusion I searched/ for "likeness" of her God". How true this is, for even if we attempt to join in the rituals of our patients, per their request, our attempt should be to find the likeness of their God. We know inherently that their comfort comes from their personal theology, and to bring maximal comfort we try to fit our words into their world view.

I love that his response then isn't to spout off his own words and prayers but to lead her to action. She is led to commune with her God, to ask, to cry out, etc.

At the end when the patient prays "never/ to die each day" I am struck with how deep her existential pain must be. I wonder how many of my patients feel as if the are dying each day, over and over again? And yet, she ends with the plea "never/ to really die", as if death will not bring the relief she is seeking either.

The skill in poetry is to take all of the emotions, thoughts, history and reality of an encounter and in very few words allow that situation to transcend to the reader. I'm sure the story of this moment could have been written out in prose, taking pages to recount. Yet, Dr. Hirsch leaves us with such a precise feeling of this patients struggle in just 22 short lines. Well done!

PDF version: Hirsch, EZ "To the End of Her Life". The Pharos. Winter 2007, pg 19