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Editor's Column

Celebration and Thanksgiving

Martin McKneally
Martin McKneally

Over 1500 "friends for life", admirers and family filled Saint Paul's Anglican Church on Bloor St. on May 14th. Everyone was talking, smiling and clearly proud to be at the aptly named "Celebration and Thanksgiving" for the life of Dr. Robert Bruce Salter. We celebrated his heroic vision of life, his courtly manners and generous spirit. John Wedge recalled Bob's missionary work, his remarkable scientific contributions that helped millions, and his rebellion against the rigid dogma of strict immobilization of fractures. We learned that Bob wore the machine that he invented to bed himself, as the first participant in the many studies of continuous passive motion he conducted to develop this remarkable treatment. He spent hours writing letters to advance the careers of his 390 fellows. In the words of his former student, Alvin Lin, he couldn't help himself from striving to do more. His last day of work at the Hospital for Sick Children was on March, 30th, six weeks before he died at the age of 83. See also The Surgical Spotlight, Spring 2010.

In contrast, the July issue of the Journal of the American Medical Association contains an editorial by UCLA geriatrician David Rubin, describing an increasingly common tragedy. His functionally impaired 89-year old patient had required a 24-hour per day caregiver - before suffering a massive stroke. She was subsequently tortured to life with intensive care. Her son insisted on this course of treatment, confusing his hopes with his filial duty, and ignoring the cost of this degrading array of medical services. "For her, it was the age of hopelessness, the worst of times. Because of her son's decisions she was maintained in a state that most would not want."

In the August 2nd issue of the New Yorker magazine, the able surgeon scientist and author Atul Gawande chronicled the last days of other tragic patients, many of them from his own practice. He dissects the language that he, like all

of us use to encourage and reassure our patients. "85% of patients respond, some of these responses can be long term". His vivid language is arresting. "I am running a warehouse for the dying", says a grieving intensivist. Dying is no longer a brief process and "last words hardly seem to exist anymore". Atul describes his own mistakes in discussing terminal illness. "When asked 'Is she dying?' I didn't know how to answer the question". Available at http://www.vimeo.com/12492922, this excellent exposition ends on a positive note, describing his surprising and enlightening experience visiting patients on rounds with a home hospice nurse, and an optimistic account of how the enlightened residents of LaCrosse, Wisconsin manage the issue of terminal illness - 85% of them have written advance directives.

Our medical system is excellent at trying to stave off death with eight -thousand-dollar-a-month chemotherapy, three-thousand-a-dollar-a-day intensive care, five-thousand-dollar-an hour surgery. But, ultimately, death comes, and no one is good at knowing when to stop.

As for the last words, they hardly seem to exist anymore. Technology sustains our organs until we are well past the point of awareness and coherence.

Atul Gawande

Demographers describe the "rectangulation of the life curve" by advances in medicine. Arthroplasty, stents, pacemakers, pharmaceutical science and other advances all help to preserve the quality of our lives, and spare us the slow declining curve of disability and discomfort associated with chronic illness in an earlier era. As fortunate beneficiaries of these medical advances, we should be grateful, and apply them wisely.

When death comes to call, the interview should be brief. Paraphrasing Dylan Thomas, we should then "go gently into that good night", without prolonging "the dying of the light". Bob Salter set an example for us all, living a full and productive life, that ended shortly before a joyous funeral of thanksgiving. I plan to celebrate and give thanks for my life at an Irish wake while I am still alive to enjoy it, followed by a grateful and willing departure.

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