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April 13, 2020

Advance Care Planning and “The Love Song of J. Alfred Prufrock”

Author Affiliations
  • 1Kennedy Institute of Ethics, Georgetown University, Washington, DC
JAMA Intern Med. 2020;180(6):813-814. doi:10.1001/jamainternmed.2020.0796

Recent articles have proposed improving care at the end of life through new forms of advance directives, better advance care planning conversations, or artificial intelligence (AI).1-6 Although these novel efforts might prove marginally beneficial, they appear to miss the bigger picture. T. S. Eliot’s poem, “The Love Song of J. Alfred Prufrock”7 (eAppendix in the Supplement), first published in 1915, considers the need to act under uncertainty and in the face of our certain mortality. The poem can help us to understand why personal and cultural transformation are more important than legal documents, planning, scripted conversations, or AI.

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    8 Comments for this article
    Baffling Commentary on Advance Care Planning, POLST, etc.
    Karl Steinberg, MD CMD HMDC HEC-C | California State University Shiley Institute for Palliative Care
    As a hospice & palliative medicine specialist and post-acute and long-term care geriatrician, I was mystified and disappointed at this piece. I love good poetry, but strongly disagree with the premise of the article.

    Advance care planning and associated documents are useful, and in a profound way.  To suggest that they are only "a tad" helpful is irresponsible and dismissive.

    Compare a situation where patients, their families, and doctors/healthcare providers all have (relative) peace of mind because they've discussed what they want and don't want to a situation to where everyone is panicking,
    digging in their heels in opposite directions, and just agonizing in the patient's last minutes, hours, days, weeks... it is night and day, not "a tad" different.

    Does it solve our fear and ignorance about what death is? Of course not! That's not the point of advance care planning. Maybe the mystery of death is the "bigger picture," and we are not going to solve that. It's not in our job description. But we can help people be comfortable that they are honoring a loved one's wishes and beliefs at the end of life. Calling advance care planning discussions and documents "marginally beneficial" when we see every day how helpful they are (and how awful it can be when they have never occurred) is disappointing indeed.

    The article was disheartening and the point mysterious! Why generate an unsolicited, negativistic criticism of one thing that we are clearly doing better than we used to, and that helps patients, families and our health care teams immeasurably?
    T.S. Eliot, Dylan Thomas and POLST
    Arthur Derse, MD, JD | Center for Bioethics and Medical Humanities, Medical College of Wisconsin
    Since POLST has been shown to be more than a “tad” effective in honoring patient wishes at the end of life,[1] it can help those who are not afraid of death and accept it -- and those who wish to “[r]age, rage against the dying of the light.”[2] POLST helps clinicians follow patient wishes rather than trying to sort things out frantically in the moment and can be of great comfort to families who know that wishes are respected.

    Reading Eliot’s poem together might help us in experiencing the mystery of life and confronting the
    inevitability of death. At the reading, if a frail elderly person collapses, having a POLST will be better for the patient, for family and friends, and for the clinicians.

    [1] Richardson DK, Fromme E, Zive D, Fu R, Newgard CD. Concordance of out-of-hospital and emergency department cardiac arrest resuscitation with documented end-of-life choices in Oregon. Ann. Emerg. Med. 2014;63:375-383.

    [2] From The Poems of Dylan Thomas, published by New Directions. Copyright © 1952, 1953 Dylan Thomas. Copyright © 1937, 1945, 1955, 1962, 1966, 1967 the Trustees for the Copyrights of Dylan Thomas. Copyright © 1938, 1939, 1943, 1946, 1971 New Directions Publishing Corp. Available at: https://poets.org/poem/do-not-go-gentle-good-night Accessed Apr. 14, 2020.
    Against the unknowable
    Paul Schneider, MD | Kaiser Permanente Tyson School of Medicine
    I personally find Sulmasy’s piece stunningly brilliant. The reason lies in his use of the phrase, “absolutely mysterious.” Akin to Arthur Cohen's descriptor of the holocaust as The Tremendum, his essay aptly regards our understanding of death not so much as unknown, but as unknowable.

    I strongly agree that the medical proclivity has been to fetishize data, i think, in an attempt to make a bulwark, communal defense against the unknowable. To my mind advance care planning is absolutely necessary to our living and dying, but insufficient by nature. How could it possibly be sufficient at the chasm? It
    is perhaps sufficient for many individuals who may be very practical by nature, and that is great for them and their loved ones. Perhaps Sulmasy might have emphasized that more. Or to emphasize more that advance care planning is not futile, just inadequate to the enormity of the task of understanding death. But to those bothered by contemplations of meta-ethics, or even religion/spirituality, there will per force be a great void in the face of death. Poetry and liturgy capture that void. Data do not. To me, personal transformation and attainment of wisdom is really what it is all about in terms of standing bravely at the chasm. To the extent that advance care planning can aid in that aspiration, I am all for it. Paul Schneider, MD, FACP, HCE-c
    A "perfect" system would eliminate being human
    John Brungardt, PhD (Philosophy) | Newman University, School of Catholic Studies
    Sulmasy’s essay reminded me of another passage from T. S. Eliot, specifically the following lines in “Choruses from the Rock”:

    «They constantly try to escape
    From the darkness outside and within
    By dreaming of systems so perfect that no one will need to be good.»

    This follows what Sulmasy has said here: “Algorithms and prediction instruments, ironically, exercise tyranny over the true freedom of moral agency that we claim to be respecting in our patients. They trap patients in their own pasts.”

    The “system” constituted by an algorithm, or a heuristic for decision-making, or even a written
    civil law is always abstracted or removed from the concrete context where a choice for the good must be made, or the truth seen. When the time comes to apply the abstract rule, the law made for general cases, or the plan made ahead of time, the concrete details of time, place, and context may present unforeseen difficulties. (This is why many philosophers and jurists have argued that those responsible to act can act against the letter of the law, even if the law is a good one, in those cases where following such a law would lead to an evil result.)

    Sulmasy shows the need for human goodness in those concrete circumstances when he writes “Yet none of these [data, planning, documents] can overcome the existential reality of death or the uncertainty inherent in ethical decision-making.” Our human deaths are of their nature incommensurate with even the most helpful and advanced of plans. Hence the need for prudence and wisdom, because the depths of goodness and truth that fulfill our humanity measure us—our systems cannot measure them.

    The ancient Greek philosopher Plato argued that the best human life is lived in preparation for dying well. Sulmasy’s essay is excellent for reminding us that fully human preparation for death cannot be fully systematized.
    Poetic but Unrealistic; Our Lives are Stories and Poems
    David Grube, MD | Compassion & Choices
    The summation is poetic in and of itself, but as a physician who has cared for many dying patients, and who currently chairs the ethic's committee of our local hospice, I find it unrealistic and academic. Constructing advance care plans, by whatever name, is invaluable in eliciting the values and wishes of the dying in order that her or his last 'chapter' can be written not as we, the clinicians, would provide, but rather, as the terminally ill person would ascribe. These plans are not perfect, but the conversations that we all have as they are developed do, indeed, make a huge difference. Not a tad.
    More than a the words on a page...
    Charles Mills, MD, FACP, FAAHPM, HMDBC | Elliot Health System, Manchester, NH
    I wanted to commend the author for this excellent and insightful commentary. Beyond the clinical realities of uncertainty, his words strike true for the full panoply of what we as clinicians must forge ahead through at this time, be it social injustice/unrest or pandemic.
    The author's insights about not being trapped in a papered repository of plan but rather tapping our own humanity to engage for us and our patients the given conditions of uncertainty that define life ring true to me. Other commentators have taken offense at the implied limitations of ACD forms/structure by the author. I don't
    think he was saying to abandon all of these definitional forms/structures.
    Rather I think that he was affirming as did TS Elliot the frailty of all forms of communication and the need for our human instincts to connect with patients in these most challenging conditions of their life. That primary reliance will allow us and any tool we choose to use its validity without being fraught with the temporality of the moment of its creation.
    Beautifully said. Thank you for saying it.
    Charlie Mills, MD, FACP, FAAHPM, HMDBC
    Medical Director, Hospice Medicine
    Elliot Health System,
    Manchester, NH
    Wonderful article!
    Aaron Newcomb, D.O. | Family & Addiction Medicine Shawnee Health Services in Carbondale, IL
    I just wanted to say this article is a real gem and I am encouraged by those in my field that grasp the true humanity of life and acknowledge its ambiguity as well as our limitations.
    James Whiting, MD,CM | PVAMC
    A minor cavil, but in the appendix, the epigraph lacks an important diacritical mark that mangles it.
    It's not non torno vivo alcun,
    which might be awkwardly translated as I don't come back alive nobody,
    but non tornò vivo alcun which means no one has come back alive.

    That's how Dante wrote it, and how Eliot quoted it:


    Of course, there are innumerable reputable sources that make the same mistake. Mannaggia!