The death of Ivan Ilych: A blueprint for intervention at the end of life

Abstract

Medical practice and the field of humanities frequently intersect. It is uncanny how problems presented or described in literature that are several hundred years old still present themselves to us on a regular basis. Often, our answers to these dilemmas are not perfect, but we continue our attempts at providing solutions through an enlightened evolution of our thought and approaches. Leo Tolstoy's novella, The Death of Ivan Ilych, is a classic piece of literature that allows a view of the dying process in an ordinary human being, and presents us with an opportunity to observe, not only the intersection of medicine and humanities, but also that of critical care and palliative medicine. Here Tolstoy, through his keen observation of the human condition at the end of life, allows us an opportunity to view a 19^th century perspective that has an all too familiar persistence that needs a 21^st century intervention.

INTRODUCTION

When dying, most patients tend to re-examine their lives and look for validation of their existence and their lifetime of efforts. While many dying patients recognize their situation, some do not. Nearly all fear their demise, most hope for a pain-free journey, and some may even revisit spirituality and/or religion. This issue of IJCIIS presents an in-depth symposium on end-of-life issues. It is difficult to dwell on the topic of “end-of-life” without Leo Tolstoy's The Death of Ivan Ilych[1] creeping into the margins of the discussion. It is one of Tolstoy's greatest works, wherein the reader is presented with an omniscient view of a man (a judge) who goes through life modeling his existence along the lines of others (aristocrats), with an inordinate lack of self-examination and prioritization of those closest to him. In the prime of his life, he becomes ill, engages all manner of medical consultation, goes through the denial of the severity of his illness, eventually realizes he is dying, undergoes extensive suffering, and finally exits this world lamenting the life he lived and realizing that there may have been a better road taken. Here, literature imitates life and leaves us with questions regarding where we can effectively intervene in the important issues of the dying process as exemplified by Tolstoy's tale.

DISCUSSION

Why the concern over Ivan Ilych's death? He was an ordinary man who aspired for creature comforts that most people seek while leading their ordinary life. He had an ordinary death, one of physical and spiritual distress. Nearly all of us face this “ordinariness,” especially in death. This “ordinariness” makes him especially important to us. While Tolstoy's story is deep and multilayered as to symbolism and interpretation, the fact remains that we observe the physical and spiritual suffering of a man who is timeless. He married because it was the correct societal thing to do, whether he loved his wife or not was almost immaterial to him. She occupied a necessary and traditional position. His children were a necessary addition to his life, as was the type of position he held and its privilege and pay. He desired to exhibit the correct manner of dress, and the correct manner of décor in his home. He gave little thought to the appropriateness of this approach to his life. Through his denial of illness, suffering, self-realization of what he could have done better in life and with relationships, acceptance of his fate, and the ultimate peace he found at the end of life, he becomes not only our patient but he becomes us. The distress his spirit endured echoes an eternity.

In Tolstoy's 19^th century example of the suffering of a solitary man, we find a 21^st century blueprint for the collective intervention of the healthcare community on behalf of those at the end of life. In other words, what Ivan Ilych endured can be remedied to a great extent through carefully crafted approaches to the dying patient by the critical care and palliative medicine communities. In examining Tolstoy's example from yesterday, we find similar concerns today regarding the recognition of dying, physician prognostication, pain, intensity of care, spirituality and religion, and end-of-life communication. Tolstoy confirms our perceptions of where end-of-life intervention should occur.

First, recognition of the dying patient is important because only about half of dying patients realize that they are actually dying.[2] This need for recognition of dying also applies to family members and even physicians themselves. Physicians must help families through this painful recognition process. Such a need is evident in a passage in the novella, in which Ivan Ilych is finally confronted with his impending doom by the mere glance of his brother-in-law, “Coming home and going into his study, he found there his brother-in-law, a healthy, ruddy man, engaged in unpacking his trunk. He raised his head, hearing Ivan Ilych's step, and for a second stared at him without word. That stare told Ivan Ilych everything.”[3] This led Ivan to the realization that, “…here I am, wasting away, no light in my eyes. I think of how to cure the appendix, but this is death. Can it be death?”[4]

Tolstoy's work also highlights the lack of situational awareness on the part of Ilych's wife. The brother-in-law needed to make it clear to his sister that her husband was dying. “No, you’re exaggerating,” Praskovya Fyodorovna (Ilych's wife) was saying. Her brother responded, “Exaggerating? You can’t see it. Why, he's a dead man. Look at his eyes, there's no light in them.”[5] This is an example of a centuries old dynamic wherein even those closest to the dying do not fully grasp the ramifications of an illness. Here, again, is identification of an actionable situation where modern critical care and palliative medicine teams have the opportunity to intervene with guidance and support.

Second, prognostication has not been a long suit of physicians.[6] Ivan Ilych consulted several physicians regarding his condition, and as Ilych discovered then, as is the modern day situation, that physicians were poor prognosticators,

“The same month he consulted another celebrated doctor. The second said almost the same as the first, but put his questions differently, and the interview with this celebrity only redoubled the doubts and fears of Ivan Ilych. A friend of a friend of his, a very good doctor, had diagnosed the disease quite differently; and in spite of the fact that he guaranteed recovery, by his questions and his suppositions he confused Ivan Ilych even more and strengthened his suspicions.”[7]

This is an old example of a weakness in the approach of physicians to predicting outcomes, which is now being addressed by new tools.[8]

Pain, of course, has always been a concern at the end of life, and Ilych's situation then was no different than those of patients now. The pain was “Gnawing, agonizing pain never ceasing for an instant,”[9] and his pain control was inadequate, “Oh, the medicine. Pyotr, give me my medicine. Oh well, may be, medicine may still be some good. He took the spoon, drank it. No, it does no good. It is all rubbish, deception, he decided, as soon as he tasted the familiar, mawkish, hopeless taste.”[10]

Nowadays, medical teams intervene promptly and effectively, but still a patient's pain is undertreated frequently. Furthermore, then as now, tachyphylaxis to medications was a problem, “He slept less and less; they gave him opium and began to inject morphine. But this did not relieve him.”[11] Giving enough medication and the correct medication effectively has always been challenging.

Although we have intensive care units and special cancer wards now, in the 19^th century, they too made attempts to provide and upgrade the intensity of care when needed, “Special arrangements also had to be made for his other physical needs, and this was a continual misery to him. Misery from the uncleanliness, unseemliness, and stench, from the feeling of another person having to assist in it.”[11] The 21^st century attempt at effectively treating critical illness requires not only a physical arena supported by appropriate modern technology, but also a multidisciplinary team approach that must include palliation of the body and the psyche.

Critical illness leads to despair, and this is not new, “Ivan Ilych saw that he was dying, and was in continual despair.”[12] For this reason, we now have palliative care teams that need to work closely, not only with the patients and families, but also the critical care teams. Palliative care team involvement should occur early and frequently. With despair, there is also denial and blame. The alliance between palliative care and critical care can also assist the patients and families in checking their denial and blame. The problem occurs now, as it did then. Even though Ilych knew that his situation was grave, he would intermittently and frequently be in denial. On arrival home, just after previously deducing that a physician had summed up a bleak picture, his wife could not stand for his tedious details of office visit. She sent the servant to get his newly prescribed medicine and to him she said, “Well I’m very glad, now you must be sure and take the medicine regularly.” She had barely left the room when she commented, “Well, maybe it really is nothing as yet.”[13]

As is evident in the previous passage this denial also extended to his wife, who was frequently resorted to blaming the patient and overlooking his concerns, “Praskovya Fyodorovna's external attitude toward her husband's illness, openly expressed to others and to himself, was that Ivan Ilych was to blame in the matter of his illness, and that the whole illness was another injury he was doing to his wife. Ivan Ilych felt that the expression of this dropped from her unconsciously, but that made it no easier for him.”[14]

After traversing despair, denial, and blame many patients eventually discover that spirituality and religion are important,[15] as they were with Ivan Ilych, “He cried out at his own helplessness, at his awful loneliness, at the cruelty of people, at the cruelty of God, at the absence of God.”[16] Many patients will also ask, as Ilych did, “Can it be I have not lived as one ought?”[17] The lack of enlightened intervention by others at this juncture can lead to further mental anguish. “The doctor said that his physical sufferings were terrible, and that was true; but even more terrible than his physical sufferings were his mental sufferings, and in that lay his chief misery.”[18]

Physicians must fashion an attitude whereby they tolerate all religious, agnostic, and atheistic beliefs because, in the end, patients seek comfort in the solace of what they know best and with what makes them most comfortable. Most importantly, physicians should never take all hope away as doing so is cruel, “When the priest arrived and Ivan made his confessions, he softened, and felt as it it were a relief from his doubts, and thus from his sufferings, and there came a moment of hope.”[19] While hope may seem delusional in many scenarios, its possibility must be allowed to persist as a matter of comfort.

Finally, anything involving the end-of-life needs effective physician communication and empathy, let alone sympathy,

“Just as brilliantly the doctor made his summing-up, and triumphantly, gaily even, glanced over his spectacles at the prisoner in the dock. From the doctor's summing up, Ivan Ilych deduced the conclusion that things looked bad, and that he, the doctor, and most likely everyone else, did not care, but that things looked bad for him. And this conclusion impressed Ivan Ilych morbidly, arousing in him a great deal of pity for himself, of greater anger against this doctor who could be unconcerned about a matter of such importance.”[20]

In the end, Ivan Ilych came to a resolution and acceptance, but it was a difficult, distressing, and lonely journey. While death is unquestionably a lonely journey, it is a journey that today's practitioners can better support through enlightened intervention by an effective multidisciplinary approach.

CONCLUSION

Tolstoy's The Death of Ivan Ilych, although fictional, was representative of a time in his life when he questioned himself as to “how to live,” and whether he had lived well. It was also a time when he accepted religion. Nonetheless, his religion and personal trepidations and failures aside, he leaves us with a story of a dying man who is suffering. His novella is an important example of the often instructive intersection between the fields of humanities and medicine. In this important portrait of a 19^th century character, Tolstoy leaves the 21^st century medical community a blueprint for places and opportunities to intervene in the physical and mental suffering of those who are dying, as exemplified in this symposium on the end of life scenario.