Abstract
Cynthia X. Pan, Rice Water Publishing, 2024, 300 pages, Cost: $18.99.
Death is an essential yet under-discussed part of being human. At some point, everyone will encounter serious illness, dying, and death. Having tools to approach these challenging moments is essential. As an expert in hospice and palliative care, Dr. Cynthia X. Pan provides valuable insight into how we can make meaning out of these end-of-life encounters. In her book, Exit Strategies: Living Lessons from Dying People, Dr. Pan describes both personal and professional experiences. With each story, she offers practical guidance for patients, caregivers, and clinicians on navigating both dying and serious illness so that people can find joy in the limited time they have near the end of life. With humility, candor, and, most uniquely, humor, Dr. Pan reminds readers of the humanity within dying.
Dr. Pan begins by sharing her unlikely path to becoming a palliative care physician, recounting the naivete with which she initially approached life. She recalls how early in medical school, she believed a patient who insisted that he only drank “a little” from a bottle of alcohol kept under his bed. Gradually, she learned to manage her social anxiety through jokes and humor. As she became drawn into the field of medicine, she appreciated learning about pain management and caring for older adults. After the death of her grandmother, she experienced a lack of closure. She turned her focus to palliative care, with the hope of helping her patients in a way that she was not able to provide for her grandmother. She acknowledges the fear and sadness within death and dying while also appreciating the “brutal honesty, refreshing resilience, tender loving, and amazing courage.”
After this personal introduction, Dr. Pan shifts the reader’s attention to advance directives, highlighting the importance of communication at the end of life. She describes how she elicits patients’ wishes for their care, recognizing that goals-of-care conversations are often unpredictable, as patients, caregivers, and healthcare providers all enter these conversations with unique baggage and agendas. Dr. Pan skillfully bridges each of these constituencies by offering a shared language. Approaching encounters with curiosity, she enters each conversation with the goal of forming a relationship with the patient. She encourages patients to “make sure their feelings are heard” and to actively engage in these difficult conversations. She recognizes the moral distress that comes when patients and families disagree about goals of care, as well as the cultural humility that is necessary when having these conversations.
Following her discussion of advance directives, Dr. Pan shares a wide range of personal and professional vignettes involving food, music, family, spirituality, birthdays, and even sex. These everyday topics that define humanity remain relevant in this period of end of life, even though a patient’s relationship with them may change. For instance, foods that a patient once loved may be less enticing. The experience with music can evolve so that it is incorporated to celebrate life; Dr. Pan even encourages readers to choose their own “end-of-life theme song.” People may experience new physical, financial, or spiritual pain; rely on their faith more at the end of life; or even begin to question their beliefs. With each vignette, Dr. Pan uniquely and sensitively incorporates humor into her writing, recognizing it as an underutilized way to cope with serious illness. She emphasizes how humor can remain distinct from simply deflecting fear or creating a distraction. Instead, it offers a way to grapple with difficult moments and provides an opportunity to establish connection.
As an intern in a combined internal medicine-psychiatry program, I have left the hospital many evenings struggling to make sense of the suffering I have witnessed. The lessons in Exit Strategies provided much-needed relief as I entered February of my intern year. I have observed that a common response to stressful and difficult encounters is often for people to become closed off, shielding themselves from the emotional turmoil. Dr. Pan’s stories remind me of the strength in vulnerability. There are ways to incorporate humor in order to find meaning and build connection even in the most challenging patient encounters. I am also reminded that there are many ways to prepare for death and dying that are not necessarily morbid, whether it is talking with family about their wishes, making a bucket list, or simply picking my own eventual walk-out song. This book should be required reading for clinicians across disciplines caring for people with serious illness as we try to make sense of the senseless without taking ourselves or our work too seriously.