Free The Way We Die Now by Seamus O'Mahony

dual role: to read the map and direct you accordingly, but also to be with you on the terrain, a place of great uncertainty. When one meets the most senior clinical staff, one is left with a sense of technical competence, undermined with some notable exceptions, by a hesitation to be brave [my italics]. Eye contact is avoided when one strays off the clinical map on to the metaphysical territory – I am a man devoid of hope – and circumlocution displaces a compassionate exploration of my worst fears. Perhaps, as a doctor, I present an unusually severe challenge to my fellow clinicians – I am too much like them – and the horror of what lies before me deflects clinical carers from straying onto that territory. No one can imagine the unimaginable except those, like me, who are experiencing it.
    But one’s journey to this bleak place can be rendered more bearable if everyone who shares a professional role at the various staging posts bears the bleakness of the terminus in mind... In the care I have received, the transactions have been timely and technically impeccable. But the relational aspects of care lacked strong leadership and at key moments were characterized by a hesitation to be brave. What I have always feared in illness was anonymity, being packaged, losing control, not being able to say ‘this is who I am’. In the end, one is left alone, here, in the kingdom of the sick.
    It is telling, that in this short and powerful piece, Sweeney used the phrase ‘a hesitation to be brave’ twice. He died on Christmas Eve of the same year, 2009. He had been an original and eloquent commentator on medicine and its wider role. He drew attention to the limitations of evidence-based medicine, coining the term ‘the information paradox’ to describe the danger of information-overload distracting the doctor from his core role of relieving suffering. Here is an extract from his obituary in the British Medical Journal :
    He later described this approach as metaphysical and in a prescient piece he wrote, ‘The clearest example of this transition to the metaphysical level occurs when someone starts to die or accepts that death is near. Here both the doctor and the patient are confronted by the question: “When is enough, enough? This”, he wrote, “will be the defining question for the next generation of practitioners.”’
THE DIFFICULT CONVERSATION
    Enough, indeed. A word rarely used in American medicine, where the culture of medical excess is most unbridled. Atul Gawande, the American surgeon and writer, became famous for championing safe surgical practice by adopting practices from other spheres of human activity such as the aviation industry. He writes regularly for the New Yorker , which published a long piece by him in 2010, called ‘Letting Go: What should medicine do when it can’t save your life?’ This article formed the basis for his 2014 book, Being Mortal. He described how, in the US, dying patients are routinely subjected to futile and painful medical treatments, while their doctors fail to discuss with them the inevitable outcome: ‘Patients die only once. They have no experience to draw on. They need doctors and nurses who are willing to have the hard discussions and say what they have seen, who will help people prepare for what is to come – and to escape a warehoused oblivion that few really want.’
    But doctors are no longer brave enough. They increasingly see themselves as service-providers, a role that does not encourage Difficult Conversations, or a willingness to be brave. Consumerism, fear of litigation and over-regulation have conspired to create the customer-friendly doctor, who emerged when the doctor–patient relationship became recast in a quasi-commercial mould. This type of doctor, well trained in communication skills, eminently biddable, is not what Kieran Sweeney or Atul Gawande had in mind. Doctors, by the nature of their selection and training, are conformist, and the now dominant