Obituaries, death and dying

I make no apology that I have included two obituaries honouring Paul Tessier in this issue. An obituary is an opportunity to ‘give an account of the texture and the significance of the life of someone who has recently died’. David David and Barry Jones are exceptional Plastic, Reconstructive and Aesthetic Surgeons in their own right but they would not be where they are today, professionally, if they had not had the opportunity to meet Paul Tessier. Standing on the shoulders of giants is the nature of human progress. There can be few in our profession who cannot identify those who have directly or indirectly critically influenced their personal and professional development. I openly acknowledge that I was deeply impressed by the gentle giants, Ian Muir, Dennis Bodenham, Maurice Kinmouth – white haired, infinitely wise and fundamentally human – how could any junior doctor not want to be a Plastic Surgeon having glimpsed at the lives of such inspiring figures. It was quite a shock to learn later that such Plastic Surgeons are rare and the sharp, pin stripe suite brigade form the majority of the ‘signed up members’. I would like to see more obituaries in this journal. I realize that taken out of context such a statement could be misconstrued! I wish all our readers and members of our profession a long and happy life and, as has been highlighted in recent editorials, a long and healthy retirement. 1, 2 But, death is a fact of life and inevitably our teachers, our inspirational figures, our esteemed colleagues will die. I would welcome contributions from anyone who wishes to put pen to paper and share with us the ‘texture and significance of the life’ of someone they honour. I know that in the British Medical Journal there used to be occasional ‘fillers’ about memorable patients and whilst we incorporate such a feature, albeit in a more formalized and objective construct as a case report or communication I do feel, again, that we can all share, on a more subjective level, lessons that we have been taught by our patients. The whole essence of Plastic, Reconstructive and Aesthetic Surgery revolves around quality of life, improvement in form and function, and we rarely address the very significant role that we can play in the quality of death and dying. In this respect I would like to share with you a very formative experience for me as a young specialist. It can be lonely as an autonomous practitioner and decisions taken in the night, with no-one to turn to can be particularly harrowing. I know Susan will want me to share her story with you because she taught me so much about dignity and joyfulness in the face of death. Harry Umpleby, the most compassionate breast surgeon I have ever met, introduced me to Susan late one Friday evening. She had advanced breast cancer, very advanced. The options had all run out, no more radiation, chemotherapy, no more conventional surgery and yet a painful, foul smelling fungating recurrence was erupting from her right axilla. I think Harry knew me better than I knew myself at that stage in my career. Is there anything that Plastic Surgery can offer this patient? I caught the look of both pity and alarm on Susan's face when I asked to see the problem. Her ‘recurrence’ was covered in a special charcoal dressing and as this was gently unraveled I realized the significance of her non-verbal ‘warning’ (Figure 1). Susan was in pain, her right arm hung oedematous at her side but her greater concern was that her cruel cancer had created distress for those around her. The smell. It was truly nauseating and both her teenage children had had to leave the family home to stay with relatives. Her husband could not hug her without gagging. For Susan, her life, her death was an absolute misery. My response was simple; no problem, I will get you in next week and make a big hole and fill it. Absolutely no question of cure but I can get rid of the smell. It will be risky entering the axilla; there could be uncontrollable bleeding, you could lose your arm, die. And so Susan was admitted and added to a busy list for excision of tumour and vertical rectus reconstruction. This was over fifteen years ago in the UK, before the emasculation of surgeons by managers in the politicization of the NHS. So to the operation; every one had friar's balsam on their mask and the recurrence was excised but it was evident that there was a ‘rice-speckling’ of pleural secondaries and I felt reluctant to perform a reconstruction that would compromise respiratory function and prolong the hospital stay. I unscrubbed to phone the husband to discuss the options and after a brief emotional but focused exchange returned to theatre and flayed the right arm and used this to close the wound. On my rounds the next morning I was stopped by the ward sister who wanted to warn me that Susan was rather emotional and in tears. I entered her room somewhat apprehensively and there she was sitting up in bed with her family around her with tears streaming down her face. What a wonderful woman, she immediately recognized my concern and said ‘tears of joy!’ For the first time for weeks her children had been able to hug her and, forget the arm, the smell, yes the smell, was gone. She was out of the hospital 48 hours later and the children moved back to the family home (Figure 2). Six weeks later I bumped into an oncologist who told me that Susan had been admitted to hospital with bronchopneumonia. The ‘Old Mans Friend’. I thought it was a nice way to ‘go’. But no. They thought her quality of life was so good that she was treated with intravenous antibiotics and she had returned home. A month later she booked to go on a short cruise with her husband and bought a beautiful dress to wear for the Captain's dinner. The night before the cruise she died, very quickly. I went to the funeral with Irene Buckley, a totally committed breast care nurse who had given Susan strength and support throughout the entire course of her illness. Susan was a wonderful woman; I felt privileged to be her surgeon albeit for such a short time. In Hong Kong I now work with an exceptional orthopaedic tumour surgeon, Shekhar Kumta, in the sarcoma service. We share our expertise for the benefit of patients and it is so important to find colleagues who have common values with regard to both quality of life as well as dignity of death. Professor Kumta is, for me, such a person, bold, brave, absolutely caring and a superb surgeon. Together we have accumulated quite an experience of aggressive palliative surgery for regionally advanced girdle tumours. The message for my younger colleagues is to remember that Plastic, Reconstructive and Aesthetic Surgery is a specialty which celebrates life but also can embrace death and dying as an opportunity to make a positive difference.

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Figure 1 The problem.

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Figure 2 The solution.