Late-20th-century Americans have often been accused of denying the inevitability of death. One of the speakers at the Dartmouth Medical School Bicentennial Symposium two years ago put that fact especially colorfully: "The Scots regard death as something actually quite imminent; Canadians tend to look on it as inevitable; and in California . . . it's simply one of the options." Health-care economist Robert Evans offered that witty characterization as cultural background for a discussion of health-care rationing. But it's also an apt, if irreverent, introduction to a subject that is the focus of a pair of features in this issue of Dartmouth Medicinethe care of the dying, also known as palliative care.
Flippancy in the face of death is not just an artifact of this decade and this country, however. The British novelist and playwright W. Somerset Maugham, a few months before he died of tuberculosis in 1965, said to his nephew Robin: "Dying is a very dull, dreary affair. And my advice to you is to have nothing whatever to do with it."
The inclination to joke about something so serious is perhaps understandable. We make light of deathas well as deny its inevitabilitybecause it's a subject that makes us uncomfortable. This is not to say that humor has no place in the sickroom, of course. Laughter has been regarded as a powerful ally in the healing process ever since the publication of Norman Cousins's 1979 memoir, Anatomy of an Illness as Perceived by a Patient. And appropriate humor can also be a fitting companion for dying patientsa balm for the psyche even when the physiology is beyond cure. Yet jokes about death are often not a considered, conscious choice, but an awkward, defensive reaction. When we're in doubt about how to act, when we feel emotionally unsettled, it's all too easy to practice either escapism, by making light of a situation, or avoidance, by refusing to admit it exists.
The goal of palliative care is to help counter those utterly human reactions when we or someone we love is nearing death. Palliative-care coordinators, and other caregivers sensitive to the principles of palliative care, help patients and their families find ways to explore and express emotions fear, grief, sadness, even angerthat are otherwise often unacknowledged. That means patients' own preferences as to the manner and place of their deathrather than someone else's assumptions about themcan be taken into account during the last stages of their illness.
Our first feature on the subject, on page 28, is a collection of three personal essays. And the second, on page 32, describes several major DHMC initiatives aimed at improving end-of-life care.
This issue also contains two "beginnings" worthy of notein the form of new names on the masthead. Jonathan Weisberg has been our editorial assistant since August. A 1996 graduate of Dartmouth College, he has nearly completed a master's in English literature at NYU. He has also worked as a publishing associate for an investing newsletter in New York City and as a research assistant for an Upper Valley company that gathers statistical data on the entertainment industry. His long-term interests lie in publishing, and we're pleased to have him honing them here. Note his byline on page 6 of this issue; his less visible but no less valuable contributions include dogged factchecking and literate copy-editing.
And in November, Laura Carter joined the staff as associate editor. She, too, is not new to Dartmouth, nor even to Dartmouth Medicine. She's been a public affairs coordinator and legislative specialist for DHMC since 1995 and has contributed several articles to the magazine as a freelancer most notably the cover feature in the Fall 1998 issue, on DMS astronaut Jay Buckey. Her previous experience ranges from editing a science newsletter for a nature preserve in New York State, to writing a children's book on plastics recycling, to working on an engineering magazine, to serving as an editorial intern at Natural History Magazine while she was earning a master's in science journalism at NYU. She is both a bona fide science junkie and a thoughtful and versatile writer (her office walls sport a photo of an Australian bulldog ant on one side and a framed poem titled "The Bookworm" on the other). Readers will see her byline regularly, including, in this issue, on a feature (page 40) and a "Vital Signs" story (pages 6-7).
I need no prompting to express my emotion about having them both hereit's delight!
Dana Cook Grossman, Editor
Dana Cook Grossman
Laura Stephenson Carter
Megan McAndrew Cooper
Martin A. Grundy, Ph.D.
Elizabeth Tucker Marshall, M.D.
Thomas J. Prendergast, M.D.
Roger P. Smith, Ph.D.
Flying Squirrel Graphics
Jon Gilbert Fox
Joan Crane Barthold, M.D., '85
James L. Bernat, M.D.
Judith E. Frank, M.D.
Mahlon B. Hoagland, M.D.
Mirna Jusufbegovic '01
Katherine J. Little, M.D.
Fred Louis III, DC '58
Thomas L. McFarland
Joseph E. Melton, Ph.D., '82
Maureen S. Micek, M.D., '90
H. Worth Parker, M.D., HS '75-83
Heinz Valtin, M.D.
Jennifer Vines '02
Charles R. Wira, Ph.D., '70
Derrik F. Woodbury, M.D., '77
EDITORIAL OFFICESMailing address: Dartmouth Medicine,
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(HB 7070), Lebanon, NH 03756 Delivery address: Dartmouth Medicine,
Two Buck Road (Door with Green Star),
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