Palliative care’s road to acceptance as standard-of-care practice has been a remarkably unsmooth one, given its core mission: improving the quality of life of patients and their families by relieving the pain, symptoms, and stress of a serious or life-limiting illness. A person’s relationship with mortality is the single common human experience, and although the thought of dying is unsettling, it can be made less so by knowing that, in many cases, a “good death” is made possible by practitioners of palliative care, such as Sunita Puri, MD, the author of the medical memoir That Good Night: Life and Medicine in the Eleventh Hour, a thoughtful meditation on life and its inevitable end.

Her Mother’s Daughter

The book is organized into 13 chapters, grouped in three parts: “Between Two Dark Skies,” “The Unlearning,” and “Infinity in a Seashell.” The arc of the book follows Dr. Puri as she is raised by her anesthesiologist mother and engineer father, both of whom are immigrants from India; her decision to enter medical school and complete an internal medicine residency, followed by a palliative care fellowship in northern California; and her subsequent return to practice in southern California, where her parents and brother live.

Dr. Puri is a skilled and lyrical writer who writes with passion about how palliative care specialists are working to change medicine from within, by teaching other doctors how to communicate with patients about their hopes and fears, not just the disease and treatment. It is also a very personal voyage, as she interweaves evocative stories of her family, her own life, and the patients she cares for.

When she was 5 years old, she first heard that life was temporary. While sitting on the porch with her father, gazing up at the beautiful autumn sky, Dr. Puri told her father she wished it would always remain as beautiful. “‘Everything in life—you, me, the sky—will change and then disappear,’ he told me…. I must have looked frightened; he told me not to be afraid. ‘This,’ he said, ‘is the natural order of things, something none of us can escape,’” writes Dr. Puri.

Learning About Mortality

It was the first of many conversations she would have with her parents about death and impermanence. However, despite her early education on the realities of life and death, she writes eloquently about how unprepared she was to face the suffering and death of her patients during her medical residency. Nevertheless, her experiences culminated in a choice to pursue a career in palliative medicine.

“My work in the borderland between life and death has shown me how we—doctors, patients, families—talk around, rather than about, suffering, dignity, living, and dying…. This book is my humble attempt to inspire tough but necessary conversations in hopes of easing the suffering associated with the silence around mortality,” writes Dr. Puri.

Dr. Puri uses the first four chapters to introduce herself and her family to readers. In the hands of a lesser writer, that might unspool in a solipsistic narrative, veering off from the book’s core: her maturation as a palliative care physician and patient stories that elucidate how far we have come and how far we have to go in our efforts to ease suffering.

Family Intertwined Into Narrative

For instance, she notes that she became a doctor largely because she wanted to be just like her mother, who was born in Mumbai to Hindu refugees. She vividly describes her mother’s strife during the conflicts among Hindus, Muslims, and Sikhs: “entire villages set ablaze, orange flames quivering as they consumed the homes” where my mother and her father had walked together most mornings. “Dismembered corpses bloodied fields full of sugarcane and wheat.”

“My work in the borderland between life and death has shown me how we—doctors, patients, families—talk around, rather than about, suffering, dignity, living, and dying.”

— Sunita Puri, MD

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After completing her internal medicine residency, Dr. Puri began a palliative care fellowship at Stanford University Hospital in Palo Alto. There are brief sections in her fine book where she strays into descriptions that seem more like window dressing, showing how she can turn an elegant phrase. For example, just as the reader reaches her entry into palliative care, Dr. Puri slides into an overly detailed description of her new digs, featuring a page full of sentences such as: “My street was home to trees adorned with leaves so green they seemed fluorescent; just a few months later, the same leaves would burn a deep burgundy. Across the way, a solitary willow bowed to the sky in reverence.” Metaphors like that might work in romance novels, but not in serious nonfiction narrative.

Compassion Shines Through

When Dr. Puri begins case studies, she shifts into first-person personal descriptions, using time stamps to give the reader a sense of the pacing. Readers of The ASCO Post will travel over well-known territory in much of the caring for patients with end-stage disease, but each vignette is imbued with colorful conversation and elements of the doctor-patient relationship that are unique to the field of palliative care. The author’s decency and intelligence come through, and although she is confident in her interactions, she is always humbled by the work she is doing.

She ends her book with a meditation on her aged mother, preparing her, without saying as much, for her own lonely road to death. Sometimes, the prose is a bit too flowery, but that’s a small gripe for such a fine book. That Good Night is recommended.