Abstract
Conversations on Dying tells the story of a middle-aged man dying of pancreatic cancer and reflecting on his life and experiences within the medical system. What makes the book unique, though, is that the patient is Dr. Larry Librach, a pioneer of palliative care in Canada. Author Phil Dwyer sets out to write a book on palliative care. He meets with Librach, a professional colleague of his wife, to discuss the project, a scene that he describes in the book's early pages.
Soon after their initial meeting, Librach is diagnosed with incurable pancreatic cancer and Dwyer's project takes a drastic and tragic turn. Librach's role in the story is no longer that of an expert consultant; he is now “Larry” the patient at its center. He is dying and he enrolls in the very program he helped found.
Over the next 200 pages, Dwyer and Librach have a series of conversations about the experience of dying and receiving palliative care in Canada. Librach is an insider—he understands the intricacies of the healthcare system from having spent a career working in and reforming it. In long passages that read as monologues, Larry is able to speak as an advocate both for the field and for himself as a patient. He effectively situates his own illness experience within the broader context of a system that does not always make dying well one of its utmost priorities. It is here that Conversations on Dying is at its most effective and poignant.
Dwyer gives readers a glimpse into Larry's emotions—for example, the fear he experiences when he awakens delirious and in pain after a procedure. His words are powerful but also heartbreaking. One cannot help but ask if Larry cannot die well with all of his connections and expertise, who can?
Ambitiously, Dwyer also attempts to use Larry's stories as a springboard to consider larger themes within palliative and end-of-life care. Dwyer provides discussions, some short and some long, on topics such as breaking bad news and physician aid in dying. He also seeks to make the clinical context of Larry's illness understandable to a lay audience. It is a laudable goal and he is generally successful. For a relatively short book, its scope is quite broad. With that said, Dwyer seems to be less comfortable describing these admittedly difficult and nuanced topics. Whereas Dwyer is adept at crafting passages that convey emotion, when describing concepts such as jaundice, his language comes across as somewhat forced, and occasionally overwrought.
Conversations on Dying also tells another story—Dwyer's. Interspersed between his conversations with Larry, Dwyer recounts his experience as his brother, John, died of tracheal cancer in England. It is this story that inspired Dwyer to embark on his initial palliative care project and it is intensely personal. We feel Dwyer's pain and shock as he lays eyes on a man lying in a hospital bed who is a faint shadow of the “mythic figure” of his older brother. John's story also serves as a contrast to Larry's. Although Larry had his own trials, he dies surrounded by family and, to the extent it is possible, in control of his story. John, in contrast, is voiceless—literally so, because of a tracheostomy. Although the stories run in parallel and complement each other, they also break up the overall narrative structure of the book. Each jump between Toronto and Manchester forces readers to refocus their attention, disrupting the emotional impact of some of Dwyer's most powerful passages.
The dual narrative of Conversations on Dying also betrays a larger tension within the book. Dwyer has known Larry for a long time and develops an even stronger relationship with him over the course of the book. As a result, Dwyer serves not only as Larry's interlocutor but also as a central character in the story. We learn of Larry's diagnosis as Dwyer and his wife receive the news and the ensuing paragraphs point out how deeply Dwyer himself was affected, both personally and professionally, by the story he sought to tell. Far from a detached and objective scribe, Dwyer becomes intimately connected to his subject. What becomes clear after reading this section is that what follows is neither merely the biography of Larry, his family, and his cancer, nor is it just a discussion about end-of-life care in the Canadian medical system, although these are all elements of the story. It is instead a story about Dwyer as he processes his brother's death through the writing of this book.
Do these issues about whose story it is matter, though? At its core, Conversations on Dying is the story of an author's relationship and last conversations with a friend dying of cancer. Even if the narrative is an amalgam of Larry and Dwyer's, does this make it less appealing or make its implicit call for more humane care for the dying less compelling? Larry Librach's life's work was to give agency to patients to whom the medical system said there was nothing left to do. In the end, Dwyer's book does this for Larry, allowing his voice and passion for end-of-life care to reach a broader audience, even after his premature death. And for that reason, it is a conversation worth reading.