That Good Night: Life and Medicine in the Eleventh Hour

Book Title: That Good Night: Life and Medicine in the Eleventh Hour

Author: Sunita Puri

Publication Details: Penguin Random House, 2020, 320 pages, $18.00 paperback

Family physicians offer care from cradle to grave. We midwife patients into and out of this world. People notice the nuances of end-of-life care intently, and getting it right is essential. In Dr Sunita Puri’s book That Good Night, she worries,

In the borderland between life and death . . . we—doctors, patients, families—talk around, rather than about, suffering, dignity, living, and dying. We rely on euphemism, silence, and jargon when we most acutely need to be clear and articulate.

The author helps us better understand, through patient stories and her own foibles, how to be better with our bedside manner and language in the 11th hour.

While this is Dr Puri’s freshman book, she is no stranger to writing. She has been published in The New York Times, The New Yorker, and JAMA. She is an internist who has served as medical director on the faculty at the University of Southern California and as program director of the Fellowship for Palliative Care at University of Massachusetts Chan Medical School.

Her book is part how-to and part personal journey. Early in the book, we join the author as she makes her way through medical school, providing astute observations about the care we offer patients, including the lack of time we actually spend with them. She notices that when she is with the palliative care team, she feels uncomfortable yet inspired, human and humane, and this feels different than other medical care. We learn about the influence of her physician mother on her career decision, including observations when she accompanied her mother to the hospital as a child. These early chapters will inspire students to find their own calling within the breadth of options for a medical life. So, too, she tells us about her mentors, Drs McCormack and Nguyen, and the influence of their role modeling—a reminder to us all to keep looking for coaches, advisors, and confidants.

Throughout the book we explore her life as a clinician who offers end-of-life care. The role offers few easy answers and plenty of gray areas. It can be frustrating when colleagues do not understand your specialty and even your family has doubts about your career decision. She takes time to offer the reader a thorough look at the depth of care offered, including community-based palliative care and home visits. She explains many palliative concepts, specifically offering five very practical steps for using words and silence to comfort, educate, and empathize. Learners and practicing clinicians will cherish these suggestions the next time they sit with a family contemplating difficult decisions for a loved one. She also reminds us that despite all the advancements across the spectrum of medicine, sometimes all we can offer is to hold someone’s hand. A powerful message indeed, especially when clinicians are asking, how can we compete with artificial intelligence?

Dr Puri takes palliative care to places that may be unfamiliar to some. She introduces concepts like undoing. We learn a lot in medical training about how to do things, but not much about undoing those things—removing breathing tubes, stopping ineffective care, and transitioning care to comfort. We use words like "fighter" or "miracles," but the “body has its own language” (p. 230). Undoing also can involve learning how to apologize and admit mistakes. The author boldly explains her relationship with science alongside mystery and the divine. There is a needle to thread here, and she artfully accomplishes the feat. She creates a series of images that makes palliative care more accessible. One image that appealed to me was the idea of titrating words like doses of medications.

This book will stimulate those who value medical humanities and writing. She invokes famous authors from Ernest Hemingway to Rainer Maria Rilke. In the chapter titled “Words,” she writes, “Words and silence, like needles and catheters, could harm or help, illuminate or injure” (p. 29). That chapter is beautifully written. Like reading other physician-writers, such as Abraham Verghese and Atul Gawande, simply experiencing her cadence and imagery can be a pleasure. Ultimately, this is a book of stories. The patients that Dr Puri shares with us within these pages teach us and inspire us. There is something in this book for medical professionals at every level and for others hoping to better understand one of the most difficult aspects of medicine and life.