Hippocrates. Aristotle. Edgar Allan Poe. Henry Beecher. As author Dr. Haider Warraich points out, what these luminaries of science, philosophy, literature, and medicine had in common was an uncommon interest in the definition of death, or more aptly, when and how death actually occurred. These many years later, we still don’t know the answer to these profound questions. This is the central theme elaborated by Warraich, a physician-in-training just starting his career in cardiology. His writing has a compelling narrative style, à la House of God meets Being Mortal meets Sapiens, A Brief History of Humankind.

Warraich weaves stories from his experiences as a medical resident in a busy urban intensive care unit (ICU) into an interesting admixture of biology lesson, history of medicine, social commentary, medical ethics review, and evolving policies and politics about dying in America. As he attempts to demystify dying and death (a brave but quixotic effort), he succeeds at illuminating how fear of death has positively influenced medical progress, resulting in a predictably longer life span for most people. Conversely, he points out in graphic detail—with images that rekindle the countless soul-wrenching experiences and memories of most physicians-in-training—how technology has influenced medicine, oftentimes driving physicians, patients, and their loved ones alike to counterproductive, harmful prolongation of dying.

The essential pivot-point of Western medicine’s decision-making revolves around the tenet to “do no harm.” This becomes the unspoken subtext of the book, implicitly challenging the reader to confront the construct of “harm” within the context of modern medical practice, wherein almost every death in the ICU, at least, is choreographed around withdrawal of some form of life support. And even though the use of hospice in the United States has increased over the last several years, the majority of those who receive this form of palliative care are referred very late in the game, leaving behind both exhausted caregivers and depleted bank accounts. Challenging life prolongation at any cost as the apotheosis of modern medicine, his message is a thinly disguised plea to revisit and reinfuse relationship and compassion as the core elements of care.

Why should anesthesiologists read this book? If for no other reason, here is an internist who appreciates the value of our specialty, as evoked in an opening passage of the book: “My attending, an anesthesiologist with Jedi-master skills, stood by me….” Beyond that poetic, metaphorical bit of interprofessional flattery is the inescapable reality that has shaped our field since its origins in resuscitation, critical care, and pain relief. Whether in the emergency department, the operating room, the ICU, or the hospice, anesthesiologists have skills that can immeasurably improve life or merely salvage it. This book may not have all the answers, but it stimulates all the right questions in all 13 chapters of highly relatable prose.

Warraich begins by providing a crisp review of cellular demise at the most elemental level. This is the most didactic portion of the book, but it is made relevant by interspersed tales from the bedside. He captures the essence of the living–dying continuum in relationship to health versus disease at the biologic level in his pithily worded statement, “…the only thing worse than a cell that forgets how to live—is one that refuses to die.”

From that starting point, he moves on to a sprint through history, highlighting the annals of medical and public health–related innovations that have led to our most recent epoch of relatively long average life expectancy. Chapter 3 (“Where Death Lives Now”) will be of particular interest to anesthesiologists as it recalls the inception and evolution of cardiopulmonary resuscitation. This is the point that he introduces the continually running theme of medical ethics, religious views, and social mores into the equation. He starts this thread by recounting the seminal case of Karen Ann Quinlan and reminding us of the notable 1957 address by Pope Pius XII to a group of anesthesiologists. In that meeting, the Pope clarified that physicians had no duty to prolong medical treatment in the face of no hope of recovery against a patient’s wishes.

From that point on, the author proceeds to outline difficult and often heart-wrenching cases, elucidating the absence of a bright line dividing living and dying in the rapidly growing, aging population with chronic progressive illnesses, or the ever-evolving definitions of brain death. The chapters “How Death Was Redefined” and “When the Heart Stops” rekindled memories of the challenging and highly practical polemic embodied by the question “when is dead really dead?” exemplified by issues brought to the fore in Anesthesiology by Gail Van Norman.1 

Subsequent chapters take a more sociological and theological turn, exploring the role of societal views as they pertain to the experience of dying and death. This theme is encapsulated in the statement “Modern medicine has done much to stave off death but little to ameliorate peoples’ fear of dying.” He proceeds to probe, question, and thoughtfully challenge the culture of modern health care, averring that that “…physicians have critical conversations with individuals without any knowledge of their spiritual fingerprints.”

The final chapters focus on the social and economic impact of systematic “death denial.” Although this line of often-contentious discourse has become pervasive in medical and political circles of late (as witnessed by the rapid rise in “aid in dying” legislative activity around the country), Warraich approaches these issues both critically and with a degree of sensitivity that is more helpfully thought-provoking than off-putting or divisive. He leaves the reader on an uplifting note, providing some hope that the hallmark of dying for so many—the desperate loneliness of debilitating illness—might find reprieve in the connectedness that modern communication technology (e.g., social media; telemedicine) might provide.

In conclusion, I found this book to be interesting, thought-provoking, highly relevant, and informative to contemporary anesthesiology while also being entertaining. In my experience, this combination is rare in medically oriented books.

Van Norman
Another matter of life and death: What every anesthesiologist should know about the ethical, legal, and policy implications of the non-heart-beating cadaver organ donor.