I once worked with wombs and now I specialize in death. I’ve learned that the end is as sacred as the beginning | Kae Sheen Wong

I think about death all the time.

I used to think about birth all the time. That’s because I worked with wombs; for years I worked exclusively in obstetrics and gynecology. Then I became a palliative care physician.

I have, as my mother likes to say, moved from the womb to the graves.

I have to admit that, in order to have a conversation, I tend to introduce myself as a gynecologist. It is almost certain that I will get an “awwww”, while palliative care invariably leads to a ceremony that is not always convenient. It takes time to explain that palliative care is not just about helping people die. It is about helping our patients live as well as possible, before they die.

We do this by helping with symptom management, including but not limited to pain, nausea and shortness of breath. But good palliative care goes beyond this. It should be supportive and enabling as patients and their loved ones navigate the most difficult journeys of their lives.

I have often told you why I went into palliative care. It wasn’t because I was burned out. I loved my work in obstetrics and gynecology and had the amazing luxury of a very diverse career. My relationships with patients and colleagues energized and fulfilled me.

But in mid-2018, a beloved aunt told me that she had read a profile of a palliative care doctor in a Malaysian newspaper. Her husband, she said, clearly needed this doctor’s services! She was absolutely right, but I barely knew what palliative care was then. Three months later, our hospital coincidentally welcomed the region’s first ever palliative care specialist.

These dual events piqued my curiosity. The more I discovered about palliative care, the more I was drawn to it. I loved the specialty I was working in, but palliative care intrigued me intellectually and emotionally. Modern medical specialties typically make it their business to deconstruct patients into solvable problems. Palliative care aims to reconstruct them as whole people, in the hope of achieving a better-late-than-never, meaningful recovery. Or, at the very least, to be a compassionate witness to their experience of loss. (There is a Chinese proverb that illustrates how many palliative care patients feel: pun ga pat leong. It means that people have effectively lost half of themselves and are no longer whole.)

The nagging idea that I should work in palliative care was so persistent that I decided to read the Oxford Textbook of Palliative Medicine. I thought it would either disabuse me of my fanciful ideas, or at least provide a basic test of determination and courage.

That huge text has a very rich content, but what struck me again and again was the emphasis on hope. “Hope is an essential assessment and intervention tool in palliative care.”

At the same time I thought: hope is also the core of obstetrics.

There are many similarities between these two specialties that I have had the privilege to practice. I reflect on these, as well as the differences between them, with growing wonder.

I have been present at thousands of births. Every moment the baby emerges, no matter how it is born, I am filled with a deep reverence. These are sacred times. One second it is all struggle; the next it is new life. And it is never a life in solitude. The new life comes to us and enlarges us in that way. Possibilities reach out ahead – this new being has innumerable potential, an infinite number of paths to unfold.

I have been present at many deaths now, and I feel a sacredness in these moments that is equal to birth. Unlike birth, however, death marks the end of potential, a sealing of loss. If our patient has left things unsaid or undone, they will now never be said or done again. People usually die as they live.

In the presence of good palliative care, suffering is minimized and hope is maximized. I believe this with all my heart and soul. Good obstetric care similarly minimizes suffering and maximizes hope for a healthy mother with her healthy baby. While death necessarily brings loss, I have seen that for some, at least, there is the balm of gratitude. When the dying person’s life ends, those they leave behind can feel a gratitude for their legacy that provides lasting comfort.

Plato said that “the greatest error in the treatment of disease is that there are physicians for the body and physicians for the soul, although the two cannot be separated.” Palliative care explicitly recognizes the importance of spirituality, the soul. Obstetrics and gynecology do not, but should. Both specialties require a thoughtful mastery of technical know-how. The body must be respected, with evidence-based treatment, even as we remember the primacy of the soul.

Ultimately, what begins and ends with the emergence and extinction of life is not just organ function. We are all soul traders, and in this truth lies mystery and privilege.