Blue nights

Age and Ageing 2012; 41: 820 © The Author 2012. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: Book review Blue nights Joan Didion Vintage, 2011, 188 pp, ISBN: 978-0-307-38738-7 I am old enough to once have had the privilege of working with Prof. John Brocklehurst, one of the founders of academic geriatric medicine. He was spending a sabbatical year in Saskatoon, helping to found the Division of Geriatric Medicine at the University of Saskatchewan. In 1979, he told me, a couple of years before I was to go to medical school with the intention of becoming a geriatrician, ‘Don’t worry about geriatric medicine in Canada. The argument is right and time is on your side.’ Much has worked out since then, but it is not so clear now, stalled as we and our American colleagues are in our recruitment efforts, whether time is still on our side. For this reason, and others, I am always alert to the possibility of new ways to engage young doctors—typically medical students or junior medical residents—about geriatric medicine. As do many of our tribe, I see the care of older adults who are frail—i.e. those whose multiple, interacting medical and social problems put them at an increased risk of adverse health outcomes—as the core of our professional activity and expertise. And like many others, I recognise that to care for such patients requires not just a set of facts and skills at hand, but a set of attitudes. Part of the affective learning required of students of geriatric medicine is an empathetic understanding of the not uncommon sense of bewilderment of their limitations that many of our patients experience. That is not readily to hand in most clinical encounters, so that when an opportunity such as that afforded by Joan Didion’s description of her experience of falls, frailty and health-care becomes available, it deserves to be made widely known. At 55, I am also old enough to remember the author in her prime. Joan Didion is a Los Angeles born but New York-based author, novelist and screenwriter. Her style of what is often called ‘literary nonfiction’ contributed to the then New Journalism, in which subjectivity in reporting was not just acknowledged, but celebrated as a means of providing a deeper understanding of events than the traditional ‘just the facts, ma’am’ standard. To do this effectively requires that the writer’s voice be recognisable, not just as a style, but as a localisable perspective and set of values. Her political writing, especially in the New York Review of Books, which is where I first read her work in the 1970s, combined that voice and those values with an admirable incisiveness. In 2005, Didion published ‘The Year of Magical Thinking’, a searing account of her grief following the 820 sudden death of her husband of four decades, the writer John Gregory Dunne. At that time, their daughter Quintana Roo Dunne was in a New York Intensive Care Unit, with septic shock arising from a pneumonia. Shortly after recovering from that, and while visiting Los Angeles, Quintana had an intracerebral haemorrhage. At the close of ‘The Year’, she was undergoing a slow recovery. Quintana Roo never did recover. She died almost 2 years (and three more ICUs) later. ‘Blue Nights’ is about that period. For the wavering medical student or resident coming to grips with the often merciless optimism of procedurefocused medicine, there is much in ‘Blue Nights’ to show how our patients gradually come to know better than to believe what we tell them, no matter how artfully we might hedge the final outcome. For the ones interested in the idea of the interior life of their patients, and what they can teach us about frailty, this book is especially insightful. Didion describes how the evaluation of a seemingly straightforward syncope resulting in an injurious fall can demoralise the patient even as it frustrates the staff. She suffered a sudden loss of consciousness, (‘… I found myself waking on the floor of my bedroom [bleeding]…I had no clear memory of falling.’) ( p. 142) and then being caught up in the medical machine. She notes the resentment of some healthcare team members when 4 days of heart monitoring failed to reveal a cardiac cause for her syncope; their view was that ‘because I had been given a bed on the cardiac unit I must have a cardiac problem’. To a Canadian sensibility, the ensuing level of investigation (four days of cardiac monitoring, MRI, MRA, PET) seems extravagant. That it proved unrevealing does not surprise. Didion describes a sudden fear of falling as she tries to arise from a folding chair at a rehearsal of the off-Broadway play based on ‘The Year’. She had insight into the apparent unreasonableness of her fear, but no way to feel differently. Frailty has impaired her body. It has compromised her relationships with others and has led her to resent their pity even as she appreciates their concern. It has affected what she feels even if it has not entirely affected how she thinks. But it has not affected her ability to observe and to react. In this way, she does a special service to anyone who wonders what it might be like to grow old and frail. She particularly opens a window for physicians who care for such patients, or those who think that they might like to do so. KENNETH ROCKWOOD QEII Health Sciences Centre, Dalhousie University, Halifax, Canada Email: doi: 10.1093/ageing/afs123 Published electronically 4 September 2012  (...truncated)